Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LW0102X | Nurse Practitioner - Women's Health | 420749 | NY |
NPI | 1013054485 |
---|---|
Provider Name | Stacie Grant |
First Address | Buffalo, NY 14215-2210 |
Second Address | Lockport, NY 14094-3616 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/02/2007 |
Last Update Date | 13/03/2009 |