Provider Demographics
NPI:1972268092
Name:GRANT, TANISHA (RN)
Entity type:Individual
Prefix:
First Name:TANISHA
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37177 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:DADE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33523
Mailing Address - Country:US
Mailing Address - Phone:678-973-8470
Mailing Address - Fax:
Practice Address - Street 1:37177 NORTH AVE
Practice Address - Street 2:
Practice Address - City:DADE CITY
Practice Address - State:FL
Practice Address - Zip Code:33523
Practice Address - Country:US
Practice Address - Phone:678-973-8470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-03
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9457208163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRN7459208OtherRN