Provider Demographics
NPI:1962629428
Name:GRANT, MARILOU (CRNP)
Entity type:Individual
Prefix:MRS
First Name:MARILOU
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:518 HILL ST
Mailing Address - Street 2:
Mailing Address - City:DURYEA
Mailing Address - State:PA
Mailing Address - Zip Code:18642-1619
Mailing Address - Country:US
Mailing Address - Phone:570-457-0218
Mailing Address - Fax:
Practice Address - Street 1:314 OAK ST
Practice Address - Street 2:
Practice Address - City:OLD FORGE
Practice Address - State:PA
Practice Address - Zip Code:18518-1619
Practice Address - Country:US
Practice Address - Phone:570-457-7150
Practice Address - Fax:570-457-8611
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAUP004462B363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily