Healthcare Provider Details

I. General information

NPI: 1497016406
Provider Name (Legal Business Name): JENNIFER GRAYBILL DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2012
Last Update Date: 11/27/2023
Certification Date: 04/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 7TH AVE N STE 107
ST PETERSBURG FL
33705-1348
US

IV. Provider business mailing address

1111 7TH AVE N STE 107
ST PETERSBURG FL
33705-1348
US

V. Phone/Fax

Practice location:
  • Phone: 727-894-1661
  • Fax: 727-894-1430
Mailing address:
  • Phone: 727-894-1661
  • Fax: 727-894-1430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS13602
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number266937
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS13602
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: