Provider Demographics
NPI:1730406828
Name:GRUBY, MISTY ROSE (LPN)
Entity type:Individual
Prefix:MS
First Name:MISTY
Middle Name:ROSE
Last Name:GRUBY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9647 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:WESTERNVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13486-1718
Mailing Address - Country:US
Mailing Address - Phone:315-827-4219
Mailing Address - Fax:
Practice Address - Street 1:9647 RIVER RD
Practice Address - Street 2:
Practice Address - City:WESTERNVILLE
Practice Address - State:NY
Practice Address - Zip Code:13486-1718
Practice Address - Country:US
Practice Address - Phone:315-827-4219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-28
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY268339-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse