Provider Demographics
NPI:1477899037
Name:GRIMSHAW, LA REA ANN (LPN)
Entity Type:Individual
Prefix:MRS
First Name:LA REA
Middle Name:ANN
Last Name:GRIMSHAW
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 KATIE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-6269
Mailing Address - Country:US
Mailing Address - Phone:405-246-6106
Mailing Address - Fax:
Practice Address - Street 1:4400 KATIE RIDGE DR
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-6269
Practice Address - Country:US
Practice Address - Phone:405-246-6106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-28
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKL0056826164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse