=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447014279
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIEGO GRISALES NP IN FAMILY HEALTH PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2024
-----------------------------------------------------
Last Update Date | 03/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2364 LYELL AVE
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14606-5738
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-755-1705
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2364 LYELL AVENUE
-----------------------------------------------------
City | ROCHETSER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-755-1705
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. DIEGO ALEJANDRO GRISALES
-----------------------------------------------------
Credential | NURSE PRACTITIONER
-----------------------------------------------------
Telephone | 585-755-1705
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------