Provider Demographics
NPI:1437810678
Name:GRIMMAGE, ARIELLE
Entity Type:Individual
Prefix:
First Name:ARIELLE
Middle Name:
Last Name:GRIMMAGE
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 1:107 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-2803
Mailing Address - Country:US
Mailing Address - Phone:315-901-1943
Mailing Address - Fax:
Practice Address - Street 1:107 W 2ND ST
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-2803
Practice Address - Country:US
Practice Address - Phone:315-901-1943
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY323556164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY370483695OtherDRIVERS LICENSE