Provider Demographics
NPI:1346564374
Name:GRIM, JOHN (CNS-BC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:GRIM
Suffix:
Gender:M
Credentials:CNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3170 KETTERING BLVD BLDG B2ND
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1924
Mailing Address - Country:US
Mailing Address - Phone:937-991-3191
Mailing Address - Fax:937-223-9811
Practice Address - Street 1:30 E APPLE ST STE 5254A
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2939
Practice Address - Country:US
Practice Address - Phone:937-208-4200
Practice Address - Fax:937-208-4205
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-19
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA NS-11161364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health