Provider Demographics
NPI:1548358203
Name:GRANT, ROBERTA ANN (FNP C)
Entity type:Individual
Prefix:MRS
First Name:ROBERTA
Middle Name:ANN
Last Name:GRANT
Suffix:
Gender:F
Credentials:FNP C
Other - Prefix:MISS
Other - First Name:ROBERTA
Other - Middle Name:ANN
Other - Last Name:DONALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:571 SAINT JOSEPHS BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-3230
Mailing Address - Country:US
Mailing Address - Phone:607-271-2050
Mailing Address - Fax:
Practice Address - Street 1:100 JOHN ROEMMELT DR STE 204
Practice Address - Street 2:
Practice Address - City:HORSEHEADS
Practice Address - State:NY
Practice Address - Zip Code:14845-8304
Practice Address - Country:US
Practice Address - Phone:607-795-2828
Practice Address - Fax:607-795-2829
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF3347761363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02850613Medicaid
NYJ400132023Medicare PIN