Provider Demographics
NPI:1659960334
Name:GRULLON, JOSE
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:GRULLON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18033 PROMENADE PARK LN APT 404
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33548-7982
Mailing Address - Country:US
Mailing Address - Phone:787-422-9496
Mailing Address - Fax:
Practice Address - Street 1:18033 PROMENADE PARK LN APT 404
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33548-7982
Practice Address - Country:US
Practice Address - Phone:787-422-9496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-15
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9455977163WM0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn