MEDICARE: STACY LEE GRILLO LVN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164X00000X	Licensed Vocational Nurse	VN266011	CA

General Provider Information

NPI Number	:	1750723912
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACY LEE GRILLO LVN

Provider Business Mailing Address
First Line	:	11053 CASA BLANCA AVE
Second Line	:
City	:	YUCAIPA
State	:	CA
Zip	:	92399
Country	:	US
Telephone Number	:	951-956-1688
Fax Number	:

Provider Business Practice Location Address
First Line	:	11503 CASA BLANCA ST
Second Line	:
City	:	YUCAIPA
State	:	CA
Zip	:	92399-9703
Country	:	US
Telephone Number	:	951-956-1688
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/29/2013
Last Update Date	:	02/17/2026

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