Healthcare Provider Details

I. General information

NPI: 1750587457
Provider Name (Legal Business Name): ROBERTA R GRIDLEY AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2007
Last Update Date: 11/29/2024
Certification Date: 11/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7010 ROWAN HILL DR
CINCINNATI OH
45227-3380
US

IV. Provider business mailing address

2212 E COUNTY ROAD 1150 N
BATESVILLE IN
47006-8744
US

V. Phone/Fax

Practice location:
  • Phone: 731-394-1145
  • Fax:
Mailing address:
  • Phone: 317-374-4431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number2024085294
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPRN.CNP.0037844
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28188662A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.491585
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number27056431A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: