Provider Demographics
NPI:1952043671
Name:GRIJALVA, QI (APRN AGACNP)
Entity Type:Individual
Prefix:
First Name:QI
Middle Name:
Last Name:GRIJALVA
Suffix:
Gender:F
Credentials:APRN AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 E. BROAD STREET
Mailing Address - Street 2:SUITE 522
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063
Mailing Address - Country:US
Mailing Address - Phone:682-242-8970
Mailing Address - Fax:214-947-8668
Practice Address - Street 1:2800 E. BROAD STREET
Practice Address - Street 2:SUITE 522
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063
Practice Address - Country:US
Practice Address - Phone:682-242-8970
Practice Address - Fax:214-947-8668
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-12
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1074026363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily