Provider Demographics
NPI:1528302221
Name:GRUNDEN, REBECCA A (NP)
Entity type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:A
Last Name:GRUNDEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4235 SECOR RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-4231
Mailing Address - Country:US
Mailing Address - Phone:419-473-3561
Mailing Address - Fax:
Practice Address - Street 1:5916 CRESTHAVEN LN APT 216B
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-1430
Practice Address - Country:US
Practice Address - Phone:419-214-1032
Practice Address - Fax:419-214-1612
Is Sole Proprietor?:No
Enumeration Date:2012-11-19
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.14029-NP163W00000X
MI4704283041163W00000X
OHCOA 14029-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCOA.14029-NPMedicaid