Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | CT587 | CT |
NPI | 1013038223 |
---|---|
Provider Name | Carol C Grant |
First Address | Milldale, CT 06467-0792 |
Second Address | Milldale, CT 06467-0792 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/04/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
050000587CT04 | ANTHEM (01) | CT |
21997 | (02) | CT |