Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TH0100X | Health Service | 750 | OK |
NPI | 1619050895 |
---|---|
Provider Name | Dr. Elizabeth Mollette Grundy |
First Address | Vinita, OK 74301-0426 |
Second Address | Vinita, OK 74301 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/10/2006 |
Last Update Date | 08/07/2007 |