Provider Demographics
NPI:1588361034
Name:GRENKE, JENNIFER ELAINE (NP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ELAINE
Last Name:GRENKE
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 1:345 N LAKE REEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:FROSTPROOF
Mailing Address - State:FL
Mailing Address - Zip Code:33843-1737
Mailing Address - Country:US
Mailing Address - Phone:863-215-5123
Mailing Address - Fax:
Practice Address - Street 1:110 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2828
Practice Address - Country:US
Practice Address - Phone:863-215-5123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-14
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9496399163WE0003X
FL11025471363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency