Provider Demographics
NPI:1558321844
Name:GRIMM, LORETTA C (FNP)
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:C
Last Name:GRIMM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5001
Mailing Address - Street 2:DIABETES CENTER AT MEMORIAL HOSPITAL
Mailing Address - City:NORTH CONWAY
Mailing Address - State:NH
Mailing Address - Zip Code:03860-5001
Mailing Address - Country:US
Mailing Address - Phone:603-356-0796
Mailing Address - Fax:603-356-3257
Practice Address - Street 1:3073 WHITE MOUNTAIN HWY
Practice Address - Street 2:DIABETES CENTER AT MEMORIAL HOSPITAL
Practice Address - City:NORTH CONWAY
Practice Address - State:NH
Practice Address - Zip Code:03860-7101
Practice Address - Country:US
Practice Address - Phone:603-356-0796
Practice Address - Fax:603-356-3257
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN275756363L00000X
NH053177-23363L00000X, 163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110083358AMedicaid
NH30342936Medicaid
P28173Medicare UPIN
MA110083358AMedicaid
NHNP4592Medicare PIN