Provider Demographics
NPI:1154625358
Name:GRIBBIN, AMY SUSAN (BS, CCE, CBC, LPN)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:SUSAN
Last Name:GRIBBIN
Suffix:
Gender:F
Credentials:BS, CCE, CBC, LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4726 WILSHIRE LN
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11769-1450
Mailing Address - Country:US
Mailing Address - Phone:631-680-2468
Mailing Address - Fax:
Practice Address - Street 1:4726 WILSHIRE LN
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:NY
Practice Address - Zip Code:11769-1450
Practice Address - Country:US
Practice Address - Phone:631-680-2468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-03
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY246594-1164W00000X
174H00000X, 374J00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No174H00000XOther Service ProvidersHealth Educator
No374J00000XNursing Service Related ProvidersDoula
No174400000XOther Service ProvidersSpecialist