Individual
AUTUMN GRANT
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
FNP
Contact information
Practice address
1430 W USTICK RD STE 100, MERIDIAN, ID 83646-7734
(208) 286-8670
Mailing address
1430 W USTICK RD STE 100, MERIDIAN, ID 83646-7734
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
260694
AZ
363LF0000X
Family Nurse Practitioner
Primary
77541
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
260694
ARIZONA STATE BOARD OF NURSING
AZ
01
—
77541
IDAHO BOARD OF NURSING
ID
01
—
F03211332
AMERICAN ACADEMY OF NURSE PRACTITIONERS
—
Enumeration date
04/22/2021
Last updated
11/14/2024
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