Provider Demographics
NPI:1629029921
Name:GRIMMELL, FAYE (ANP/GNP)
Entity Type:Individual
Prefix:
First Name:FAYE
Middle Name:
Last Name:GRIMMELL
Suffix:
Gender:F
Credentials:ANP/GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 CENTERPOINTE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-8660
Mailing Address - Country:US
Mailing Address - Phone:503-797-2273
Mailing Address - Fax:503-234-8155
Practice Address - Street 1:13200 SW PACIFIC HWY
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223
Practice Address - Country:US
Practice Address - Phone:503-598-2000
Practice Address - Fax:503-639-0920
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR081001262N3363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR090087Medicaid
OR090087Medicaid
MG0398734OtherDEA
OR103207Medicare PIN