Healthcare Provider Details

I. General information

NPI: 1285984617
Provider Name (Legal Business Name): JUDITH GRKINICH REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2012
Last Update Date: 01/25/2023
Certification Date: 01/25/2023
Deactivation Date: 04/30/2020
Reactivation Date: 01/25/2023

III. Provider practice location address

1333 CHESTNUT AVENUE
LONG BEACH CA
90813-2944
US

IV. Provider business mailing address

1333 CHESTNUT AVE
LONG BEACH CA
90813-2944
US

V. Phone/Fax

Practice location:
  • Phone: 562-753-2301
  • Fax:
Mailing address:
  • Phone: 562-753-2301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN814931
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: