Provider Demographics
NPI:1912437625
Name:GRENER, NATHANAEL JAMES (PTA)
Entity Type:Individual
Prefix:
First Name:NATHANAEL
Middle Name:JAMES
Last Name:GRENER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 MILITARY TRL # 22-310
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-2869
Mailing Address - Country:US
Mailing Address - Phone:561-249-2958
Mailing Address - Fax:
Practice Address - Street 1:3930 US 1 S
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-7089
Practice Address - Country:US
Practice Address - Phone:904-217-0480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24259225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant