Provider Demographics
NPI:1760173447
Name:GROTJOHN, CHANEL MARIE (RN)
Entity Type:Individual
Prefix:
First Name:CHANEL
Middle Name:MARIE
Last Name:GROTJOHN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:CHANEL
Other - Middle Name:MARIE
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:11806 MARINE VIEW DR SW
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98146-2445
Mailing Address - Country:US
Mailing Address - Phone:206-854-7314
Mailing Address - Fax:
Practice Address - Street 1:1660 S COLUMBIAN WAY
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98108-1532
Practice Address - Country:US
Practice Address - Phone:206-762-1010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60349843163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse