Provider Demographics
NPI:1003584194
Name:NIMOH, GRACE A
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:A
Last Name:NIMOH
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 1:8427 DORSEY CIR
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-4596
Mailing Address - Country:US
Mailing Address - Phone:703-330-7517
Mailing Address - Fax:703-656-4893
Practice Address - Street 1:8427 DORSEY CIR
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4596
Practice Address - Country:US
Practice Address - Phone:703-330-7517
Practice Address - Fax:703-656-4893
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-02
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0002099391164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse