Provider Demographics
NPI:1902537509
Name:GRANDON, LISA J (LPN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:J
Last Name:GRANDON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2833 CENTRAL PARK WAY NE APT 204
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-3482
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1215 FULTON ST E
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-3849
Practice Address - Country:US
Practice Address - Phone:616-742-0351
Practice Address - Fax:616-742-0370
Is Sole Proprietor?:No
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4703059274364SC1501X, 164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No364SC1501XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistCommunity Health/Public Health