Provider Demographics
NPI:1003016650
Name:GRISSOM, BONNIE J (RN)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:J
Last Name:GRISSOM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PALMETTO HEALTH BAPTIST DIABETES EDUCATION
Mailing Address - Street 2:1333 TAYLOR STREET; SUITE 4-E
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201
Mailing Address - Country:US
Mailing Address - Phone:803-296-3956
Mailing Address - Fax:803-296-8908
Practice Address - Street 1:PALMETTO HEALTH BAPTIST DIABETES EDUCATION
Practice Address - Street 2:1333 TAYLOR STREET; SUITE 4-E
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201
Practice Address - Country:US
Practice Address - Phone:803-296-3956
Practice Address - Fax:803-296-8908
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-23
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC64034163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC64034OtherSTATE LICENSE