Provider Demographics
NPI:1093819278
Name:GRIBBELL, LAURA L LEE (FNP)
Entity Type:Individual
Prefix:
First Name:LAURA L
Middle Name:LEE
Last Name:GRIBBELL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 W HARRIE ST
Mailing Address - Street 2:
Mailing Address - City:NEWBERRY
Mailing Address - State:MI
Mailing Address - Zip Code:49868-1209
Mailing Address - Country:US
Mailing Address - Phone:906-293-9200
Mailing Address - Fax:906-293-9285
Practice Address - Street 1:W14034 MELLVILLE STREET
Practice Address - Street 2:
Practice Address - City:ENGADINE
Practice Address - State:MI
Practice Address - Zip Code:49827
Practice Address - Country:US
Practice Address - Phone:906-477-6066
Practice Address - Fax:906-477-1052
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704169020363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI500870240OtherBLUE CROSS BLUE SHIELD MI
MI4569556Medicaid
MIP23875Medicare UPIN
MI4569556Medicaid