Provider Demographics
NPI:1093856833
Name:GRILLO, REBECCA JUDE (PA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:JUDE
Last Name:GRILLO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 WASHINGTON AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-1724
Mailing Address - Country:US
Mailing Address - Phone:203-672-2800
Mailing Address - Fax:203-672-2801
Practice Address - Street 1:52 WASHINGTON AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-1724
Practice Address - Country:US
Practice Address - Phone:203-672-2800
Practice Address - Fax:203-672-2801
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001359363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTP95951Medicare UPIN
CT970001382Medicare ID - Type Unspecified