Healthcare Provider Details

I. General information

NPI: 1780265231
Provider Name (Legal Business Name): LAURA LYNN GRGICH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LAURA LYNN GRGICH RN

II. Dates (important events)

Enumeration Date: 04/16/2021
Last Update Date: 04/16/2021
Certification Date: 04/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 W 39TH AVE
SAN MATEO CA
94403-4364
US

IV. Provider business mailing address

83 IRVING ST
SOUTH SAN FRANCISCO CA
94080-1512
US

V. Phone/Fax

Practice location:
  • Phone: 650-573-2671
  • Fax: 650-573-2696
Mailing address:
  • Phone: 650-784-8067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number351587
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: