Healthcare Provider Details

I. General information

NPI: 1790083806
Provider Name (Legal Business Name): JACLYN GRZYBOWSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2011
Last Update Date: 03/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2605 W SWANN AVE SUITE 600
TAMPA FL
33609-4039
US

IV. Provider business mailing address

2605 W SWANN AVE SUITE 600
TAMPA FL
33609-4039
US

V. Phone/Fax

Practice location:
  • Phone: 813-876-7073
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberARNP 9248140
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: