Provider Demographics
NPI:1639166028
Name:GRISWOLD, MICHAEL FREDERICK (RNFA CNS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:FREDERICK
Last Name:GRISWOLD
Suffix:
Gender:M
Credentials:RNFA CNS
Other - Prefix:
Other - First Name:MICK
Other - Middle Name:F
Other - Last Name:GRISWOLD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RNFA CNS
Mailing Address - Street 1:72780 COUNTRY CLUB DR
Mailing Address - Street 2:SUITE A104
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-4126
Mailing Address - Country:US
Mailing Address - Phone:760-837-8020
Mailing Address - Fax:760-834-3780
Practice Address - Street 1:72780 COUNTRY CLUB DR
Practice Address - Street 2:SUITE A104
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-4126
Practice Address - Country:US
Practice Address - Phone:760-837-8020
Practice Address - Fax:760-834-3780
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA525368163W00000X
CA555364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ153092Medicare ID - Type Unspecified