Provider Demographics
NPI:1952025660
Name:GRUNDY, MYCHEALE
Entity Type:Individual
Prefix:
First Name:MYCHEALE
Middle Name:
Last Name:GRUNDY
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 1:1232 N LAYMAN AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-3106
Mailing Address - Country:US
Mailing Address - Phone:317-654-0442
Mailing Address - Fax:
Practice Address - Street 1:1232 N LAYMAN AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-3106
Practice Address - Country:US
Practice Address - Phone:317-654-0442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-27
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN87-2140837Medicaid