Healthcare Provider Details

I. General information

NPI: 1407740558
Provider Name (Legal Business Name): VANESSA GRIMALDO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2025
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 W CALL ST
TALLAHASSEE FL
32304-3556
US

IV. Provider business mailing address

1115 W CALL ST
TALLAHASSEE FL
32304-3556
US

V. Phone/Fax

Practice location:
  • Phone: 954-224-5576
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9121231
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: