Provider Demographics
NPI:1104367739
Name:GRIMM, GEORGINA GISELLE (FNP)
Entity Type:Individual
Prefix:MS
First Name:GEORGINA
Middle Name:GISELLE
Last Name:GRIMM
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 1:5018 SHAFTER AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-2221
Mailing Address - Country:US
Mailing Address - Phone:510-388-3261
Mailing Address - Fax:
Practice Address - Street 1:9925 INTERNATIONAL BLVD
Practice Address - Street 2:#5
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94603-2558
Practice Address - Country:US
Practice Address - Phone:510-777-1177
Practice Address - Fax:510-550-2644
Is Sole Proprietor?:No
Enumeration Date:2017-03-15
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95006100363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily