Basic Information
| Provider Information | |||||||||
| NPI: | 1528302221 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRUNDEN | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4235 SECOR RD | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436234231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194733561 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5916 CRESTHAVEN LN APT 216B | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436141430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192141032 | ||||||||
| FaxNumber: | 4192141612 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2012 | ||||||||
| LastUpdateDate: | 02/24/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | COA.14029-NP | OH | N | Nursing Service Providers | Registered Nurse | 163W00000X | 4704283041 | MI | N | Nursing Service Providers | Registered Nurse | 363LF0000X | COA 14029-NP | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | COA.14029-NP | 05 | OH | MEDICAID |