Provider Demographics
NPI:1851941793
Name:GRIEWAHN, KIMBERLY KAY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:KAY
Last Name:GRIEWAHN
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:PO BOX 143
Mailing Address - Street 2:
Mailing Address - City:MANITOU BEACH
Mailing Address - State:MI
Mailing Address - Zip Code:49253-0143
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17221 MANITOU ROAD
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:MI
Practice Address - Zip Code:49220
Practice Address - Country:US
Practice Address - Phone:517-206-2394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-12
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X
MI230015914320812376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7897473Medicaid