Provider Demographics
NPI:1750960142
Name:GRIGGS, KATHY BONITA
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:BONITA
Last Name:GRIGGS
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 1:4130 SALISBURY RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-8031
Mailing Address - Country:US
Mailing Address - Phone:904-729-9525
Mailing Address - Fax:
Practice Address - Street 1:4130 SALISBURY RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-8031
Practice Address - Country:US
Practice Address - Phone:904-729-9525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-05
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFV0572994172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty