Provider Demographics
NPI:1063729838
Name:GRUBB, SANDRA L
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:L
Last Name:GRUBB
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 1:2105 SIDNEYWOOD DR APT D
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45449-2651
Mailing Address - Country:US
Mailing Address - Phone:937-204-2043
Mailing Address - Fax:
Practice Address - Street 1:2105 SIDNEYWOOD DR APT D
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45449-2651
Practice Address - Country:US
Practice Address - Phone:937-204-2043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-01
Last Update Date:2025-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN 133556 IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse