1659655074 NPI number — CHALLIS A. GRIMM ARNP

Table of content: CHALLIS A. GRIMM ARNP (NPI 1659655074)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659655074 NPI number — CHALLIS A. GRIMM ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRIMM
Provider First Name:
CHALLIS
Provider Middle Name:
A.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ARNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659655074
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4371 VERONICA S SHOEMAKER BLVD
Provider Second Line Business Mailing Address:
ATTN: CREDENTIALING
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33916-2216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-274-8200
Provider Business Mailing Address Fax Number:
239-278-3350

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
917 RINEHART RD
Provider Second Line Business Practice Location Address:
SUITE 2041
Provider Business Practice Location Address City Name:
LAKE MARY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32746-4802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-804-6133
Provider Business Practice Location Address Fax Number:
321-283-4332
Provider Enumeration Date:
10/04/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  ARNP9176451 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 010861500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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