Provider Demographics
NPI:1174061709
Name:GRANT, TIA (LPN)
Entity type:Individual
Prefix:MRS
First Name:TIA
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7943 STUHLDREHER ST NW
Mailing Address - Street 2:
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44646-1967
Mailing Address - Country:US
Mailing Address - Phone:330-356-3148
Mailing Address - Fax:
Practice Address - Street 1:7943 STUHLDREHER ST NW
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646-1967
Practice Address - Country:US
Practice Address - Phone:330-356-3148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-02
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN147113-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse