Provider Demographics
NPI:1033151139
Name:GRIMM, ANNA KATHLEEN (NP)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:KATHLEEN
Last Name:GRIMM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-494-1303
Mailing Address - Fax:503-346-8021
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-1303
Practice Address - Fax:503-346-8021
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV33115363LF0000X
OHCOA.03700-NP363LF0000X, 363LA2100X
OR201501103NP-PP363LA2100X
OR201501120NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810001991Medicaid
OH0051782Medicaid
WV1067391OtherWV WORK COMP
WV3810001991Medicaid
OH0051782Medicaid
OHH104061Medicare PIN