Provider Demographics
NPI:1669756813
Name:GRIMM, NICHOLE SUZANNE (NP)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:SUZANNE
Last Name:GRIMM
Suffix:
Gender:F
Credentials:NP
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 1343
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-0863
Mailing Address - Country:US
Mailing Address - Phone:208-263-1441
Mailing Address - Fax:
Practice Address - Street 1:423 N 3RD AVE STE 201
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1511
Practice Address - Country:US
Practice Address - Phone:208-263-2221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-06
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-1113A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily