Provider Demographics
NPI:1285961607
Name:GRANT, TIFFANY
Entity type:Individual
Prefix:
First Name:TIFFANY
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 1:10961 S KEDZIE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60655-2219
Mailing Address - Country:US
Mailing Address - Phone:773-239-9100
Mailing Address - Fax:
Practice Address - Street 1:10961 S KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60655-2219
Practice Address - Country:US
Practice Address - Phone:773-239-9100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-05
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209007728363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily