Provider Demographics
NPI:1700022514
Name:RODRIGUEZ, GRISELLE
Entity type:Individual
Prefix:
First Name:GRISELLE
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GRISELLE
Other - Middle Name:
Other - Last Name:BASORA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:121 CSH UNIT 15244 BOX 653
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96205-5244
Mailing Address - Country:US
Mailing Address - Phone:910-778-5843
Mailing Address - Fax:
Practice Address - Street 1:121 CSH UNIT 15244
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96205-5244
Practice Address - Country:US
Practice Address - Phone:910-778-5843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-29
Last Update Date:2008-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN161869163WM0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn