Provider Demographics
NPI:1013714260
Name:GRANT, LONNIE MIKE
Entity type:Individual
Prefix:
First Name:LONNIE
Middle Name:MIKE
Last Name:GRANT
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 CENTENNIAL ST
Mailing Address - Street 2:
Mailing Address - City:WALTHILL
Mailing Address - State:NE
Mailing Address - Zip Code:68067-5090
Mailing Address - Country:US
Mailing Address - Phone:402-846-5660
Mailing Address - Fax:
Practice Address - Street 1:102 S BROUGHTON ST APT 106
Practice Address - Street 2:
Practice Address - City:WALTHILL
Practice Address - State:NE
Practice Address - Zip Code:68067-5150
Practice Address - Country:US
Practice Address - Phone:402-922-3671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-26
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider