Healthcare Provider Details

I. General information

NPI: 1114912508
Provider Name (Legal Business Name): SUSAN LEE GRYDER A.R.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 TECH BLVD STE 100
TAMPA FL
33619-7871
US

IV. Provider business mailing address

1202 TECH BLVD STE 100
TAMPA FL
33619-7871
US

V. Phone/Fax

Practice location:
  • Phone: 813-620-0026
  • Fax: 813-623-3322
Mailing address:
  • Phone: 813-620-0026
  • Fax: 813-623-3322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP3010512
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: