Healthcare Provider Details

I. General information

NPI: 1255210738
Provider Name (Legal Business Name): GRACE CARRASQUILLO RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2025
Last Update Date: 08/29/2025
Certification Date: 08/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 JENSEN AVE
LAKELAND FL
33815-0701
US

IV. Provider business mailing address

909 JENSEN AVE
LAKELAND FL
33815-0701
US

V. Phone/Fax

Practice location:
  • Phone: 863-812-0987
  • Fax:
Mailing address:
  • Phone: 863-812-0987
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WN0800X
TaxonomyNeuroscience Registered Nurse
License NumberRN9669770
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9669770
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: