Provider Demographics
NPI:1710493713
Name:GRUNDEN, BROOKE K
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:K
Last Name:GRUNDEN
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 1:511 PERRY ST
Mailing Address - Street 2:
Mailing Address - City:DEFIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:43512-2123
Mailing Address - Country:US
Mailing Address - Phone:419-782-9920
Mailing Address - Fax:419-784-2523
Practice Address - Street 1:511 PERRY ST
Practice Address - Street 2:
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-2123
Practice Address - Country:US
Practice Address - Phone:419-782-9920
Practice Address - Fax:419-784-2523
Is Sole Proprietor?:No
Enumeration Date:2017-12-28
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH165305OtherLICENSE