Provider Demographics
NPI:1982934857
Name:GROVENOR, AUDREY (L P N)
Entity Type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:
Last Name:GROVENOR
Suffix:
Gender:F
Credentials:L P N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11010 225TH ST
Mailing Address - Street 2:QUEENS VILLAGE
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11429-2825
Mailing Address - Country:US
Mailing Address - Phone:718-776-4683
Mailing Address - Fax:
Practice Address - Street 1:11010 225TH ST
Practice Address - Street 2:QUEENS VILLAGE
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11429-2825
Practice Address - Country:US
Practice Address - Phone:718-776-4683
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-28
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY107886-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYOSCAR1940Medicaid