Provider Demographics
NPI:1669723219
Name:GRUNDSTROM, NADINE (RN)
Entity type:Individual
Prefix:MRS
First Name:NADINE
Middle Name:
Last Name:GRUNDSTROM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:258 SW AMESBURY AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-6964
Mailing Address - Country:US
Mailing Address - Phone:772-878-5639
Mailing Address - Fax:
Practice Address - Street 1:258 SW AMESBURY AVE
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-6964
Practice Address - Country:US
Practice Address - Phone:772-878-5639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-23
Last Update Date:2012-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN 9306882163W00000X
NY627176-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse