Provider Demographics
NPI:1861620155
Name:GRANHOLM, MARY T (RN MSN APN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:T
Last Name:GRANHOLM
Suffix:
Gender:F
Credentials:RN MSN APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 TWIN LAKES DR
Mailing Address - Street 2:
Mailing Address - City:AIRMONT
Mailing Address - State:NY
Mailing Address - Zip Code:10952-4414
Mailing Address - Country:US
Mailing Address - Phone:845-356-8777
Mailing Address - Fax:
Practice Address - Street 1:20 PROSPECT AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1997
Practice Address - Country:US
Practice Address - Phone:201-336-8297
Practice Address - Fax:201-336-8296
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-25
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00189400163WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WX0200XNursing Service ProvidersRegistered NurseOncology