Provider Demographics
NPI:1942047956
Name:GRUDOWSKI, MAYNILLA (LMT)
Entity type:Individual
Prefix:
First Name:MAYNILLA
Middle Name:
Last Name:GRUDOWSKI
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5933 SCHOFIELD DR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32506-5268
Mailing Address - Country:US
Mailing Address - Phone:724-734-6541
Mailing Address - Fax:
Practice Address - Street 1:744 E BURGESS RD STE A101
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-6360
Practice Address - Country:US
Practice Address - Phone:850-696-8805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-09
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA104419225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist