Provider Demographics
NPI:1235960188
Name:GRANT, CARRIE A (PMHNP)
Entity type:Individual
Prefix:MRS
First Name:CARRIE
Middle Name:A
Last Name:GRANT
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 W CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-3320
Mailing Address - Country:US
Mailing Address - Phone:224-704-2223
Mailing Address - Fax:
Practice Address - Street 1:809 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-3320
Practice Address - Country:US
Practice Address - Phone:224-704-2223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-12
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209030580363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health