Basic Information
| Provider Information | |||||||||
| NPI: | 1568423317 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRIJALVA | ||||||||
| FirstName: | RITA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 260 CALLE CAMPESINO | ||||||||
| Address2: | |||||||||
| City: | SAN CLEMENTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926724553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9493661053 | ||||||||
| FaxNumber: | 9499167710 | ||||||||
| Practice Location | |||||||||
| Address1: | 1771 W ROMNEYA DR | ||||||||
| Address2: | STE C | ||||||||
| City: | ANAHEIM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145203000 | ||||||||
| FaxNumber: | 7145205742 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2006 | ||||||||
| LastUpdateDate: | 03/14/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 12425 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | GR0095540 | 05 | CA | MEDICAID |