Provider Demographics
NPI:1841431848
Name:GRONDAL, MYRIAM F
Entity Type:Individual
Prefix:MISS
First Name:MYRIAM
Middle Name:F
Last Name:GRONDAL
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 1:831 E 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32169-3307
Mailing Address - Country:US
Mailing Address - Phone:386-428-5510
Mailing Address - Fax:
Practice Address - Street 1:831 E 12TH AVE
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32169-3307
Practice Address - Country:US
Practice Address - Phone:386-428-5510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-20
Last Update Date:2009-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult Companion
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL678469179OtherBRAIN AND SPINAL CORD INJURY PROGRAM - PROVIDER #