Provider Demographics
NPI:1104199843
Name:GRIMM, NICOLE LEE (NP)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:LEE
Last Name:GRIMM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:NICOLE
Other - Middle Name:LEE
Other - Last Name:PIOTROWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:5409 VERN HOLMES DR
Mailing Address - Street 2:
Mailing Address - City:STEVENS POINT
Mailing Address - State:WI
Mailing Address - Zip Code:54482-8853
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5409 VERN HOLMES DR
Practice Address - Street 2:
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54482-8853
Practice Address - Country:US
Practice Address - Phone:715-342-1185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-10
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI184270-30163W00000X
WI7803-33363LF0000X, 363LX0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily