Individual
NICOLA GRANGER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
O.D.
Contact information
Practice address
524 CANAL ST, NEW SMYRNA BEACH, FL 32168-7012
(386) 423-5190
Mailing address
1950 OLD GALLOWS RD STE 520, VIENNA, VA 22182-3970
(703) 847-8899
(571) 223-6780
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
OPC 5177
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
017822000
—
FL
01
—
IQ6502
MEDICARE PTAN
FL
Enumeration date
07/02/2015
Last updated
09/21/2021
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