Provider Demographics
NPI:1235818410
Name:GRIM, MATTIE (RN)
Entity Type:Individual
Prefix:
First Name:MATTIE
Middle Name:
Last Name:GRIM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E RANDOLPH ST APT 1317
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-7303
Mailing Address - Country:US
Mailing Address - Phone:419-906-0611
Mailing Address - Fax:
Practice Address - Street 1:1620 W HARRISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3801
Practice Address - Country:US
Practice Address - Phone:888-352-7874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-14
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.511767163WC1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1600XNursing Service ProvidersRegistered NurseContinuing Education/Staff Development