Provider Demographics
NPI:1629324165
Name:GRILLOT, DOMINICA JOZELLE (LPN)
Entity Type:Individual
Prefix:
First Name:DOMINICA
Middle Name:JOZELLE
Last Name:GRILLOT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3888 CARMEL CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:CELINA
Mailing Address - State:OH
Mailing Address - Zip Code:45822-9769
Mailing Address - Country:US
Mailing Address - Phone:567-644-2707
Mailing Address - Fax:
Practice Address - Street 1:1101 N VANDEMARK RD
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:OH
Practice Address - Zip Code:45365-3567
Practice Address - Country:US
Practice Address - Phone:937-492-8080
Practice Address - Fax:937-492-2533
Is Sole Proprietor?:No
Enumeration Date:2012-08-02
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN 118988 M IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse