Healthcare Provider Details

I. General information

NPI: 1134413354
Provider Name (Legal Business Name): ADRIA MARIE GRILLO-PECK RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2011
Last Update Date: 06/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WYOMING ST
DAYTON OH
45409-2722
US

IV. Provider business mailing address

1 WYOMING ST
DAYTON OH
45409-2722
US

V. Phone/Fax

Practice location:
  • Phone: 937-208-5286
  • Fax: 937-341-8375
Mailing address:
  • Phone: 937-208-5286
  • Fax: 937-341-8375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberRN.204269-COA1
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: