Individual
MYRA JO GRANTHAM
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
NP
Contact information
Practice address
2302 COLLEGE AVE, CONWAY, AR 72034-6297
(501) 329-3831
(501) 450-2283
Mailing address
200 CORPORATE BLVD, LAFAYETTE, LA 70508-3870
(800) 893-9698
Taxonomy
Speciality
Code
Description
License number
State
261QS1000X
Student Health Clinic/Center
A004270
AR
363LF0000X
Family Nurse Practitioner
Primary
A004270
AR
Other
Enumeration date
02/10/2015
Last updated
06/10/2019
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