Provider Demographics
NPI:1730663824
Name:GRISSOM, MONIQUE
Entity Type:Individual
Prefix:MS
First Name:MONIQUE
Middle Name:
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 1:504 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44307-2103
Mailing Address - Country:US
Mailing Address - Phone:330-344-0210
Mailing Address - Fax:
Practice Address - Street 1:504 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44307-2103
Practice Address - Country:US
Practice Address - Phone:330-344-0210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-24
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant