Provider Demographics
NPI:1548311434
Name:WILSON-GRANBY, GEORGETTE
Entity type:Individual
Prefix:
First Name:GEORGETTE
Middle Name:
Last Name:WILSON-GRANBY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3204 HANA RD
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08817-2552
Mailing Address - Country:US
Mailing Address - Phone:972-877-5452
Mailing Address - Fax:973-877-5454
Practice Address - Street 1:111 CENTRAL AVE
Practice Address - Street 2:SMMC, EMPLOYEE HEALTH - MSH ROOM 203
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-1909
Practice Address - Country:US
Practice Address - Phone:973-877-5452
Practice Address - Fax:973-877-5454
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY302415363LA2200X
NJ26NN07778700363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health