Provider Demographics
NPI:1861580516
Name:GRANSTAFF, GINA
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:GRANSTAFF
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 1:514 TIMS WAY DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-0220
Mailing Address - Country:US
Mailing Address - Phone:615-449-5547
Mailing Address - Fax:
Practice Address - Street 1:1420 W BADDOUR PKWY
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-1510
Practice Address - Country:US
Practice Address - Phone:615-443-9036
Practice Address - Fax:615-443-9037
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPTA0000002723225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant