Provider Demographics
NPI:1265266506
Name:GRENADE, MINDY CARDINA
Entity type:Individual
Prefix:
First Name:MINDY
Middle Name:CARDINA
Last Name:GRENADE
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 1:421 CLYMER AVE
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19067-2269
Mailing Address - Country:US
Mailing Address - Phone:917-962-6111
Mailing Address - Fax:
Practice Address - Street 1:374 MOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:WERNERSVILLE
Practice Address - State:PA
Practice Address - Zip Code:19565-9219
Practice Address - Country:US
Practice Address - Phone:570-561-2990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-29
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP027447363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health