Healthcare Provider Details

I. General information

NPI: 1700022514
Provider Name (Legal Business Name): GRISELLE RODRIGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: GRISELLE BASORA

II. Dates (important events)

Enumeration Date: 12/29/2008
Last Update Date: 12/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 CSH UNIT 15244
APO AP
96205-5244
US

IV. Provider business mailing address

121 CSH UNIT 15244 BOX 653
APO AP
96205-5244
US

V. Phone/Fax

Practice location:
  • Phone: 910-778-5843
  • Fax:
Mailing address:
  • Phone: 910-778-5843
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License NumberRN161869
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: