=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487870317
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MINDY SUE GRALL ARNP, PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2007
-----------------------------------------------------
Last Update Date | 05/19/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1805 SE 16TH AVE SUITE 1202
-----------------------------------------------------
City | OCALA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34471-4672
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-732-8630
-----------------------------------------------------
Fax | 352-867-7895
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1805 SE 16TH AVE SUITE 1202
-----------------------------------------------------
City | OCALA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34471-4672
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-732-8630
-----------------------------------------------------
Fax | 352-867-7895
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | ARNP3168872
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------