Provider Demographics
NPI:1457486383
Name:GRANT, CAROL A (CRNA)
Entity type:Individual
Prefix:MS
First Name:CAROL
Middle Name:A
Last Name:GRANT
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 WALT WHITMAN RD STE 300
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-4300
Mailing Address - Country:US
Mailing Address - Phone:516-370-3861
Mailing Address - Fax:973-762-4639
Practice Address - Street 1:1 BAY AVE
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-4837
Practice Address - Country:US
Practice Address - Phone:973-429-6275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNO07563700174400000X
NJ26NJ00193000367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ035072BMBMedicare ID - Type UnspecifiedMEDICARE ID#