Provider Demographics
NPI: | 1033474580 |
---|---|
Name: | GRASSHAM, JOHANNA MARIE (RN, CDE, BC-ADM, CNP) |
Entity Type: | Individual |
Prefix: | |
First Name: | JOHANNA |
Middle Name: | MARIE |
Last Name: | GRASSHAM |
Suffix: | |
Gender: | F |
Credentials: | RN, CDE, BC-ADM, CNP |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 1515 EUBANK BLVD SE BLDG 832 |
Mailing Address - Street 2: | |
Mailing Address - City: | ALBUQUERQUE |
Mailing Address - State: | NM |
Mailing Address - Zip Code: | 87123-3453 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 505-844-4237 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1515 EUBANK BLVD SE BLDG 832 |
Practice Address - Street 2: | |
Practice Address - City: | ALBUQUERQUE |
Practice Address - State: | NM |
Practice Address - Zip Code: | 87123-3453 |
Practice Address - Country: | US |
Practice Address - Phone: | 505-844-4237 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2012-07-11 |
Last Update Date: | 2019-07-11 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NM | R49987 | 163W00000X |
NM | 2091-0361 | 163WD0400X |
NM | 56889 | 363L00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | |
No | 163W00000X | Nursing Service Providers | Registered Nurse | |
No | 163WD0400X | Nursing Service Providers | Registered Nurse | Diabetes Educator |