Provider Demographics
NPI:1407381296
Name:GRZESIK, KIMBERLY JOAN (MS, RN, AGACNP-BC)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JOAN
Last Name:GRZESIK
Suffix:
Gender:F
Credentials:MS, RN, AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:2150 GETTLER ST STE 455
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-2381
Practice Address - Country:US
Practice Address - Phone:219-922-7159
Practice Address - Fax:219-922-4020
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-28
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209015536363LA2200X
IN71015407A363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health