Provider Demographics
NPI:1568423317
Name:GRIJALVA, RITA MARIE (RNP)
Entity Type:Individual
Prefix:
First Name:RITA
Middle Name:MARIE
Last Name:GRIJALVA
Suffix:
Gender:F
Credentials:RNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 CALLE CAMPESINO
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-4553
Mailing Address - Country:US
Mailing Address - Phone:949-366-1053
Mailing Address - Fax:949-916-7710
Practice Address - Street 1:1771 W ROMNEYA DR
Practice Address - Street 2:STE C
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801
Practice Address - Country:US
Practice Address - Phone:714-520-3000
Practice Address - Fax:714-520-5742
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12425363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0095540Medicaid
P30938Medicare UPIN
WNP12425BMedicare ID - Type Unspecified