Provider Demographics
NPI:1154963809
Name:GRUNDON, ALYSSA JANE
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:JANE
Last Name:GRUNDON
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 1:1001 E OSCEOLA PKWY STE 230
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-1616
Mailing Address - Country:US
Mailing Address - Phone:407-847-6166
Mailing Address - Fax:407-847-5112
Practice Address - Street 1:1001 E OSCEOLA PKWY STE 230
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-1616
Practice Address - Country:US
Practice Address - Phone:407-847-6166
Practice Address - Fax:407-847-5112
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-15
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9408793163W00000X
FLAPRN11015726363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No163W00000XNursing Service ProvidersRegistered Nurse