Healthcare Provider Details

I. General information

NPI: 1023975075
Provider Name (Legal Business Name): SUSAN GRYZMALA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2026
Last Update Date: 03/13/2026
Certification Date: 03/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 CLAYTON RD STE 216
SAINT LOUIS MO
63117-1850
US

IV. Provider business mailing address

3453 S ILLINOIS AVE
CARBONDALE IL
62903-8363
US

V. Phone/Fax

Practice location:
  • Phone: 314-646-7848
  • Fax:
Mailing address:
  • Phone: 618-771-1108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2026001005
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2026001005
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: