Basic Information
| Provider Information | |||||||||
| NPI: | 1306485008 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRIMM | ||||||||
| FirstName: | CRESENCIA | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSNNHCECPANACNPCAG | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GRIMM | ||||||||
| OtherFirstName: | CRESENCIA CHRIS | ||||||||
| OtherMiddleName: | ANCHETA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSNNHCECPANACNPCAG | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 104 E SADDLE LN | ||||||||
| Address2: | |||||||||
| City: | HAVELOCK | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285322938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2526464820 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 511 PALADIN DR | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278347826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2527528880 | ||||||||
| FaxNumber: | 2523172092 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2019 | ||||||||
| LastUpdateDate: | 01/24/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 5012647 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.