Provider Demographics
NPI:1629660162
Name:GRISHAM, KATHLEEN V (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:V
Last Name:GRISHAM
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 MONTEREY AVE
Mailing Address - Street 2:
Mailing Address - City:CAPITOLA
Mailing Address - State:CA
Mailing Address - Zip Code:95010-3618
Mailing Address - Country:US
Mailing Address - Phone:831-464-5630
Mailing Address - Fax:
Practice Address - Street 1:620 MONTEREY AVE
Practice Address - Street 2:
Practice Address - City:CAPITOLA
Practice Address - State:CA
Practice Address - Zip Code:95010-3618
Practice Address - Country:US
Practice Address - Phone:831-464-5630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-05
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95056396163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool