Provider Demographics
NPI:1750723912
Name:GRILLO, STACY LEE (LVN)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:LEE
Last Name:GRILLO
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:LEE
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4041 OSAGE AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92509-6889
Mailing Address - Country:US
Mailing Address - Phone:951-575-9200
Mailing Address - Fax:951-686-2597
Practice Address - Street 1:11503 CASA BLANCA ST
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-9703
Practice Address - Country:US
Practice Address - Phone:951-956-1688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-29
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN266011164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse