Basic Information
Provider Information
NPI: 1316905045
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: GRIMM
FirstName: CHARLOTTE
MiddleName: L
NamePrefix:  
NameSuffix:  
Credential: APRN
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 224 HAILI ST STE B
Address2:  
City: HILO
State: HI
PostalCode: 967202975
CountryCode: US
TelephoneNumber: 8089614072
FaxNumber: 8089615678
Practice Location
Address1: 1178B KINOOLE ST
Address2:  
City: HILO
State: HI
PostalCode: 967204133
CountryCode: US
TelephoneNumber: 8089691427
FaxNumber: 8089614909
Other Information
ProviderEnumerationDate: 05/02/2006
LastUpdateDate: 03/20/2008
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
163W00000XRN43876HIN Nursing Service ProvidersRegistered Nurse 
363LF0000XAPRN 789HIY Physician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily

No ID Information.


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