MEDICARE: GRANT PRUD'HOMME RNFA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WR0006X	Registered Nurse First Assistant	470560	NY

General Provider Information

NPI Number	:	1598624918
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRANT PRUD'HOMME RNFA

Provider Business Mailing Address
First Line	:	214 KING ST STE A
Second Line	:
City	:	OGDENSBURG
State	:	NY
Zip	:	13669-1142
Country	:	US
Telephone Number	:	315-393-3600
Fax Number	:

Provider Business Practice Location Address
First Line	:	214 KING ST STE A
Second Line	:
City	:	OGDENSBURG
State	:	NY
Zip	:	13669-1142
Country	:	US
Telephone Number	:	315-393-3600
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/21/2026
Last Update Date	:	01/21/2026

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