Provider Demographics
NPI:1699437970
Name:GRANT, SHIRLEY R
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:R
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 1:529 DERRICK INN RD
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-9423
Mailing Address - Country:US
Mailing Address - Phone:912-660-5974
Mailing Address - Fax:
Practice Address - Street 1:2927 DEMERE RD
Practice Address - Street 2:
Practice Address - City:ST SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522-1620
Practice Address - Country:US
Practice Address - Phone:912-638-1999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-13
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN130320363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health