Provider Demographics
NPI:1417554106
Name:GRUBKE, ADRIANA ELISE (CPNP-PC)
Entity Type:Individual
Prefix:
First Name:ADRIANA
Middle Name:ELISE
Last Name:GRUBKE
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8742 W PARK RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:MI
Mailing Address - Zip Code:48166-9289
Mailing Address - Country:US
Mailing Address - Phone:745-775-7189
Mailing Address - Fax:
Practice Address - Street 1:22318 FORD RD
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-2421
Practice Address - Country:US
Practice Address - Phone:313-278-2788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704341112363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics