Provider Demographics
NPI:1780011619
Name:GRIMES, NATHANIEL
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:
Last Name:GRIMES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 E G ST
Mailing Address - Street 2:
Mailing Address - City:NENANA
Mailing Address - State:AK
Mailing Address - Zip Code:99760
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:806 E 6 ST
Practice Address - Street 2:
Practice Address - City:NENANA
Practice Address - State:AK
Practice Address - Zip Code:99760
Practice Address - Country:US
Practice Address - Phone:907-832-5461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-10
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker