Provider Demographics
NPI:1144791492
Name:GRISSOM, YOHA
Entity Type:Individual
Prefix:
First Name:YOHA
Middle Name:
Last Name:GRISSOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5767 DUNLAP ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-3411
Mailing Address - Country:US
Mailing Address - Phone:215-251-6236
Mailing Address - Fax:
Practice Address - Street 1:5767 DUNLAP ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-3411
Practice Address - Country:US
Practice Address - Phone:215-251-6236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103559370Medicaid