Provider Demographics
NPI:1447906565
Name:GRANGER, LANITA SHAVONN (HOMECARE PROVIDER)
Entity type:Individual
Prefix:
First Name:LANITA
Middle Name:SHAVONN
Last Name:GRANGER
Suffix:
Gender:F
Credentials:HOMECARE PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 43RD AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39307-6800
Mailing Address - Country:US
Mailing Address - Phone:601-678-9239
Mailing Address - Fax:601-830-1334
Practice Address - Street 1:314 43RD AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39307-6800
Practice Address - Country:US
Practice Address - Phone:601-678-9239
Practice Address - Fax:601-453-5920
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-28
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSLCB20190000075376J00000X
311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No376J00000XNursing Service Related ProvidersHomemaker