Provider Demographics
NPI:1487870317
Name:GRALL, MINDY SUE (ARNP, PHD)
Entity type:Individual
Prefix:
First Name:MINDY
Middle Name:SUE
Last Name:GRALL
Suffix:
Gender:F
Credentials:ARNP, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 SE 16TH AVE
Mailing Address - Street 2:SUITE 1202
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-4672
Mailing Address - Country:US
Mailing Address - Phone:352-732-8630
Mailing Address - Fax:352-867-7895
Practice Address - Street 1:1805 SE 16TH AVE
Practice Address - Street 2:SUITE 1202
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-4672
Practice Address - Country:US
Practice Address - Phone:352-732-8630
Practice Address - Fax:352-867-7895
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3168872363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3084086-00Medicaid
GA344510743AMedicaid
FLAF232ZMedicare PIN