Provider Demographics
NPI:1720625593
Name:GRYNIV, BOGDANA
Entity Type:Individual
Prefix:
First Name:BOGDANA
Middle Name:
Last Name:GRYNIV
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 1:5758 S MARYLAND AVE STE 5A
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-1426
Mailing Address - Country:US
Mailing Address - Phone:773-702-6138
Mailing Address - Fax:
Practice Address - Street 1:5758 S MARYLAND AVE STE 5A
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1426
Practice Address - Country:US
Practice Address - Phone:773-702-6138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-29
Last Update Date:2019-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209020466363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner