Provider Demographics
NPI:1235348160
Name:GRISOLIA, SALLYANN P (RT)
Entity Type:Individual
Prefix:
First Name:SALLYANN
Middle Name:P
Last Name:GRISOLIA
Suffix:
Gender:F
Credentials:RT
Other - Prefix:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:7454 EADS AVE
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-5036
Mailing Address - Country:US
Mailing Address - Phone:858-551-0285
Mailing Address - Fax:
Practice Address - Street 1:18945 FM 2252 STE 115
Practice Address - Street 2:
Practice Address - City:GARDEN RIDGE
Practice Address - State:TX
Practice Address - Zip Code:78266-2797
Practice Address - Country:US
Practice Address - Phone:210-651-0027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CARHT 828962471N0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471N0900XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistNuclear Medicine Technology