Provider Demographics
NPI:1083977821
Name:GIRON, GRACIELA (MSED)
Entity Type:Individual
Prefix:MRS
First Name:GRACIELA
Middle Name:
Last Name:GIRON
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:MRS
Other - First Name:GRACIELA
Other - Middle Name:E
Other - Last Name:GIRON-VILLACIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSED
Mailing Address - Street 1:14915 DELAWARE AVE
Mailing Address - Street 2:3FL
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-1318
Mailing Address - Country:US
Mailing Address - Phone:347-542-0516
Mailing Address - Fax:
Practice Address - Street 1:14915 DELAWARE AVE
Practice Address - Street 2:3FL
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-1318
Practice Address - Country:US
Practice Address - Phone:347-542-0516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-18
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY344613091174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY52100Medicaid