Provider Demographics
NPI:1639818180
Name:GBOLO, GRISELDA
Entity Type:Individual
Prefix:
First Name:GRISELDA
Middle Name:
Last Name:GBOLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 BEATTIE RD
Mailing Address - Street 2:
Mailing Address - City:ROCK TAVERN
Mailing Address - State:NY
Mailing Address - Zip Code:12575-5262
Mailing Address - Country:US
Mailing Address - Phone:203-409-3626
Mailing Address - Fax:
Practice Address - Street 1:75 S BROADWAY
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10601-4413
Practice Address - Country:US
Practice Address - Phone:203-409-3626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY736008163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse