Provider Demographics
NPI:1275226425
Name:GROSVENOR, RACHAEL (FNP)
Entity Type:Individual
Prefix:
First Name:RACHAEL
Middle Name:
Last Name:GROSVENOR
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 METROPOLITAN PARK DR STE 100
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-7112
Mailing Address - Country:US
Mailing Address - Phone:315-870-9369
Mailing Address - Fax:
Practice Address - Street 1:5700 W GENESEE ST STE 124
Practice Address - Street 2:
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031-3206
Practice Address - Country:US
Practice Address - Phone:315-478-4185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-01
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY351953363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily