Healthcare Provider Details

I. General information

NPI: 1700463460
Provider Name (Legal Business Name): BRITTANY ANNE GRUDZIELANEK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2021
Last Update Date: 10/08/2024
Certification Date: 10/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 S LEGACY DR STE 20
PROSPER TX
75078-2940
US

IV. Provider business mailing address

940 S LEGACY DR STE 20
PROSPER TX
75078-2940
US

V. Phone/Fax

Practice location:
  • Phone: 214-389-8801
  • Fax: 214-389-8802
Mailing address:
  • Phone: 214-389-8801
  • Fax: 214-389-8802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberV1777
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: