Provider Demographics
NPI:1124269998
Name:GRANT-ELLIS, CARON C (RN)
Entity type:Individual
Prefix:
First Name:CARON
Middle Name:C
Last Name:GRANT-ELLIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3691 W YELLOW PEAK DR
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85242-3076
Mailing Address - Country:US
Mailing Address - Phone:480-677-4160
Mailing Address - Fax:
Practice Address - Street 1:554 S BELLVIEW
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-2504
Practice Address - Country:US
Practice Address - Phone:480-649-1141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-09
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN133597163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)