Provider Demographics
NPI:1891209870
Name:GRIGG, CARLIE ALEXANDRA
Entity type:Individual
Prefix:
First Name:CARLIE
Middle Name:ALEXANDRA
Last Name:GRIGG
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 1:9130 R G SKINNER PARKWAY
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256
Mailing Address - Country:US
Mailing Address - Phone:904-538-0950
Mailing Address - Fax:904-538-0952
Practice Address - Street 1:9130 R G SKINNER PARKWAY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256
Practice Address - Country:US
Practice Address - Phone:904-538-0950
Practice Address - Fax:904-538-0952
Is Sole Proprietor?:No
Enumeration Date:2017-11-28
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA185615363A00000X
FLPA9113179363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant