Provider Demographics
NPI:1215474333
Name:GRANT, BRUESHANA
Entity type:Individual
Prefix:
First Name:BRUESHANA
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 CLINIC RD N
Mailing Address - Street 2:
Mailing Address - City:BOX ELDER
Mailing Address - State:MT
Mailing Address - Zip Code:59521-8849
Mailing Address - Country:US
Mailing Address - Phone:406-395-4486
Mailing Address - Fax:406-395-4408
Practice Address - Street 1:96 CLINIC RD N
Practice Address - Street 2:
Practice Address - City:BOX ELDER
Practice Address - State:MT
Practice Address - Zip Code:59521-8849
Practice Address - Country:US
Practice Address - Phone:406-395-4486
Practice Address - Fax:406-395-4408
Is Sole Proprietor?:No
Enumeration Date:2017-01-26
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT104339163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse