Provider Demographics
NPI:1528279403
Name:SIRAGUSA LLC DBA GRANNY NANNIES
Entity type:Organization
Organization Name:SIRAGUSA LLC DBA GRANNY NANNIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JODI
Authorized Official - Middle Name:
Authorized Official - Last Name:EARLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-894-2922
Mailing Address - Street 1:770 1ST AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-3604
Mailing Address - Country:US
Mailing Address - Phone:727-894-2922
Mailing Address - Fax:727-894-2911
Practice Address - Street 1:770 1ST AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-3604
Practice Address - Country:US
Practice Address - Phone:727-894-2922
Practice Address - Fax:727-894-2911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL30211147251E00000X
FL30211066251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL684866401Medicaid
FL684866400Medicaid