Provider Demographics
NPI:1861915761
Name:GRANT, KRYSTIN ANGEL (CNA)
Entity type:Individual
Prefix:
First Name:KRYSTIN
Middle Name:ANGEL
Last Name:GRANT
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ANNA
Mailing Address - State:IL
Mailing Address - Zip Code:62906-1652
Mailing Address - Country:US
Mailing Address - Phone:618-833-5115
Mailing Address - Fax:
Practice Address - Street 1:1000 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ANNA
Practice Address - State:IL
Practice Address - Zip Code:62906-1652
Practice Address - Country:US
Practice Address - Phone:618-833-5115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide