Provider Demographics
NPI:1598592461
Name:GRANTHAM, VIRGINIA (RN, BSN, IBCLC)
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:
Last Name:GRANTHAM
Suffix:
Gender:F
Credentials:RN, BSN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 ANNSLEE LN
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-7236
Mailing Address - Country:US
Mailing Address - Phone:706-490-2310
Mailing Address - Fax:
Practice Address - Street 1:511 ANNSLEE LN
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-7236
Practice Address - Country:US
Practice Address - Phone:706-490-2310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN205137163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant