Provider Demographics
NPI:1689964017
Name:GRUBB, DESIREE L
Entity Type:Individual
Prefix:MS
First Name:DESIREE
Middle Name:L
Last Name:GRUBB
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 1:1905 STRANG AVE
Mailing Address - Street 2:#1
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10466-2357
Mailing Address - Country:US
Mailing Address - Phone:347-335-7751
Mailing Address - Fax:
Practice Address - Street 1:781 E 142ND ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10454-1723
Practice Address - Country:US
Practice Address - Phone:718-993-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-19
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY282148164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse