Individual
GENNELL GRANT
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
619 16TH AVE S, SAINT PETERSBURG, FL 33701-5407
(727) 709-8755
Mailing address
619 16TH AVE S, SAINT PETERSBURG, FL 33701-5407
(727) 709-8755
Taxonomy
Speciality
Code
Description
License number
State
171W00000X
Contractor
Primary
MA 67006
FL
Other
Enumeration date
02/27/2015
Last updated
02/27/2015
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