Provider Demographics
NPI:1285678060
Name:GRIMM, KATHLEEN A (CRNA)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:GRIMM
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6684 MELDRUM RD
Mailing Address - Street 2:
Mailing Address - City:FAIR HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:48023-2001
Mailing Address - Country:US
Mailing Address - Phone:586-725-8062
Mailing Address - Fax:248-357-0915
Practice Address - Street 1:23901 LAHSER RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-6035
Practice Address - Country:US
Practice Address - Phone:248-357-3360
Practice Address - Fax:248-357-0915
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704114284367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIKG114284OtherBCBSM NUMBER
MIF36443024Medicare PIN