Provider Demographics
NPI:1659655074
Name:GRIMM, CHALLIS A (ARNP)
Entity Type:Individual
Prefix:
First Name:CHALLIS
Middle Name:A
Last Name:GRIMM
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4371 VERONICA S SHOEMAKER BLVD
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-2216
Mailing Address - Country:US
Mailing Address - Phone:239-274-8200
Mailing Address - Fax:239-278-3350
Practice Address - Street 1:917 RINEHART RD
Practice Address - Street 2:SUITE 2041
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-4802
Practice Address - Country:US
Practice Address - Phone:407-804-6133
Practice Address - Fax:321-283-4332
Is Sole Proprietor?:No
Enumeration Date:2011-10-04
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9176451363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily