Provider Demographics
NPI:1629184924
Name:GRANDLICH, CHERYL A (NP)
Entity Type:Individual
Prefix:MS
First Name:CHERYL
Middle Name:A
Last Name:GRANDLICH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:CHERYL
Other - Middle Name:A
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:TRAUMA AND CRITICAL CARE SURGERY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-8642
Mailing Address - Fax:414-805-8641
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:TRAUMA AND CRITICAL CARE SURGERY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-8642
Practice Address - Fax:414-805-8641
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI86036363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1629184924Medicaid
WI052V 73-601Medicare PIN