Provider Demographics
NPI:1225416530
Name:GRENNOCK, DARRELL (LPN)
Entity Type:Individual
Prefix:
First Name:DARRELL
Middle Name:
Last Name:GRENNOCK
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13548 232ND ST
Mailing Address - Street 2:
Mailing Address - City:LAURELTON
Mailing Address - State:NY
Mailing Address - Zip Code:11413-2536
Mailing Address - Country:US
Mailing Address - Phone:718-506-8221
Mailing Address - Fax:
Practice Address - Street 1:13548 232ND ST
Practice Address - Street 2:
Practice Address - City:LAURELTON
Practice Address - State:NY
Practice Address - Zip Code:11413-2536
Practice Address - Country:US
Practice Address - Phone:718-506-8221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-07
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY291286-1372500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider