Healthcare Provider Details

I. General information

NPI: 1467496232
Provider Name (Legal Business Name): GRICEL RODRIGUEZ FORN FMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 03/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 E 25TH ST SUITE #102
HIALEAH FL
33013-3825
US

IV. Provider business mailing address

PO BOX 347604
CORAL GABLES FL
33234-7604
US

V. Phone/Fax

Practice location:
  • Phone: 305-984-8422
  • Fax: 305-857-0070
Mailing address:
  • Phone: 305-984-8422
  • Fax: 305-857-0070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberRN9261633
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberRN9261633
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberRN9261633
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: