Provider Demographics
NPI:1710623012
Name:GRISSOM, SIMONIQUE JESSIE-ALLEAN
Entity Type:Individual
Prefix:
First Name:SIMONIQUE
Middle Name:JESSIE-ALLEAN
Last Name:GRISSOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3207 N ACADEMY BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-5100
Mailing Address - Country:US
Mailing Address - Phone:719-632-5700
Mailing Address - Fax:
Practice Address - Street 1:225 S UNION BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3184
Practice Address - Country:US
Practice Address - Phone:719-632-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-10
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0997794-NP363LF0000X
CO1635053163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse