Provider Demographics
NPI:1215175278
Name:GRANTHAM, STACIE K (CFNP)
Entity type:Individual
Prefix:MRS
First Name:STACIE
Middle Name:K
Last Name:GRANTHAM
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:587 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-3938
Mailing Address - Country:US
Mailing Address - Phone:731-424-8922
Mailing Address - Fax:731-423-2922
Practice Address - Street 1:587 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3938
Practice Address - Country:US
Practice Address - Phone:731-424-8922
Practice Address - Fax:731-423-2922
Is Sole Proprietor?:No
Enumeration Date:2009-01-29
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN13513363LF0000X
TNAPN13513363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily