Provider Demographics
NPI:1134280464
Name:GRUTKOWSKI, LORA LEE (RN FNP-BC ACNS-BC)
Entity Type:Individual
Prefix:MRS
First Name:LORA
Middle Name:LEE
Last Name:GRUTKOWSKI
Suffix:
Gender:F
Credentials:RN FNP-BC ACNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5883 VINE HILL ROAD
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472
Mailing Address - Country:US
Mailing Address - Phone:707-824-8200
Mailing Address - Fax:707-823-5800
Practice Address - Street 1:5883 VINE HILL ROAD
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472
Practice Address - Country:US
Practice Address - Phone:707-824-8200
Practice Address - Fax:707-823-5800
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN #365475163W00000X, 163WR0006X
CACNS #1381364S00000X
CANP #18178363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACNS013810Medicaid
CAZZZ18629ZMedicare ID - Type Unspecified
P71013Medicare UPIN