Provider Demographics
NPI:1316378797
Name:GRIMARD, JERRICO
Entity Type:Individual
Prefix:
First Name:JERRICO
Middle Name:
Last Name:GRIMARD
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 1:4747 BELLA COLLINA CT
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-7510
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3100 N ACADEMY BLVD
Practice Address - Street 2:SUITE 211
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917-5321
Practice Address - Country:US
Practice Address - Phone:719-574-0384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-10
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0164267363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily