Provider Demographics
NPI:1376168914
Name:GRINSELL, NICOLE RENEE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:RENEE
Last Name:GRINSELL
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 1:35 MILLER AVE # 190
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-1903
Mailing Address - Country:US
Mailing Address - Phone:415-297-1215
Mailing Address - Fax:
Practice Address - Street 1:1330 LINCOLN AVE STE 201
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2142
Practice Address - Country:US
Practice Address - Phone:415-459-5999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-09
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program