Provider Demographics
NPI:1538539614
Name:GRANA, KIMBERLY (NP)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:
Last Name:GRANA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:HOSKING/MCCLURE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AGPCNP-BC
Mailing Address - Street 1:311 W LINCOLN ST
Mailing Address - Street 2:STE 201
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-1902
Mailing Address - Country:US
Mailing Address - Phone:618-222-3200
Mailing Address - Fax:618-222-3203
Practice Address - Street 1:311 W LINCOLN ST STE 101
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-1902
Practice Address - Country:US
Practice Address - Phone:618-222-3200
Practice Address - Fax:618-222-3203
Is Sole Proprietor?:No
Enumeration Date:2015-10-01
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209013529363LA2200X
MO2015021523363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health