Provider Demographics
NPI:1043574627
Name:GRIDINA, LARISA (RN)
Entity Type:Individual
Prefix:
First Name:LARISA
Middle Name:
Last Name:GRIDINA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2676 W 3RD ST
Mailing Address - Street 2:APT 5B
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-6354
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2676 W 3RD ST
Practice Address - Street 2:APT 5B
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-6354
Practice Address - Country:US
Practice Address - Phone:917-676-5529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-28
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY643956-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02386450Medicaid