Provider Demographics
NPI:1033936240
Name:RODRIGUEZ, GRACIELLA
Entity type:Individual
Prefix:
First Name:GRACIELLA
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 GARDEN STREET
Mailing Address - Street 2:405
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403
Mailing Address - Country:US
Mailing Address - Phone:917-327-0677
Mailing Address - Fax:
Practice Address - Street 1:112 GARDEN STREET
Practice Address - Street 2:405
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403
Practice Address - Country:US
Practice Address - Phone:917-327-0677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-20
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VTD3B7M5A9246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy