Provider Demographics
NPI:1548889215
Name:GRADY, JENNIFER D (APRN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:D
Last Name:GRADY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4145 CASTLE GATE DR
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32571-7352
Mailing Address - Country:US
Mailing Address - Phone:850-356-5119
Mailing Address - Fax:
Practice Address - Street 1:1221 W LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-1836
Practice Address - Country:US
Practice Address - Phone:850-469-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-13
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11006096363LP0808X
FL11006096363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health