Provider Demographics
NPI:1700668126
Name:GRILLO, LISSETTE
Entity Type:Individual
Prefix:
First Name:LISSETTE
Middle Name:
Last Name:GRILLO
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 1:690 CHELTENHAM AVE
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32738-9008
Mailing Address - Country:US
Mailing Address - Phone:786-481-8383
Mailing Address - Fax:
Practice Address - Street 1:1845 HOLSONBACK DR
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5114
Practice Address - Country:US
Practice Address - Phone:386-274-0500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-19
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9352671163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health