Provider Demographics
NPI:1114008281
Name:GRANNEMAN, STEPHANIE ALVERA (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ALVERA
Last Name:GRANNEMAN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 N MARKET ST
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:MO
Mailing Address - Zip Code:63556-1316
Mailing Address - Country:US
Mailing Address - Phone:660-265-4456
Mailing Address - Fax:660-265-4627
Practice Address - Street 1:210 N MARKET ST
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:MO
Practice Address - Zip Code:63556
Practice Address - Country:US
Practice Address - Phone:660-265-4456
Practice Address - Fax:660-265-4627
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MORN086431363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO428230411Medicaid
MO501720809Medicaid
MO591720800Medicaid
MO263834Medicare ID - Type UnspecifiedRURAL HEALTH CLINIC
MOS18332Medicare UPIN
MO591720800Medicaid