Provider Demographics
NPI:1205437415
Name:GRUENWALD, LINDSEY N (PA-C)
Entity type:Individual
Prefix:
First Name:LINDSEY
Middle Name:N
Last Name:GRUENWALD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2923 CAPEN DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-6217
Mailing Address - Country:US
Mailing Address - Phone:440-477-9723
Mailing Address - Fax:
Practice Address - Street 1:900 MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61602-5003
Practice Address - Country:US
Practice Address - Phone:309-671-7772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty