Provider Demographics
NPI:1881759702
Name:GRANT, DANA LANELL (MD)
Entity type:Individual
Prefix:DR
First Name:DANA
Middle Name:LANELL
Last Name:GRANT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:297 HIGHWAY 51 STE B
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-3423
Mailing Address - Country:US
Mailing Address - Phone:601-707-5381
Mailing Address - Fax:601-707-5382
Practice Address - Street 1:1824 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-3410
Practice Address - Country:US
Practice Address - Phone:601-346-4586
Practice Address - Fax:601-346-4587
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS19338208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05025008Medicaid