Provider Demographics
NPI:1437139318
Name:GRISWOLD, CAMILLE (MSN NP)
Entity Type:Individual
Prefix:
First Name:CAMILLE
Middle Name:
Last Name:GRISWOLD
Suffix:
Gender:F
Credentials:MSN NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 SIXTH ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2701
Mailing Address - Country:US
Mailing Address - Phone:231-935-5090
Mailing Address - Fax:231-935-5093
Practice Address - Street 1:1221 SIXTH ST
Practice Address - Street 2:SUITE 206
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2701
Practice Address - Country:US
Practice Address - Phone:231-935-5090
Practice Address - Fax:231-935-5093
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704192319363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104156180Medicaid
MI104156180Medicaid