Provider Demographics
NPI:1770201220
Name:GRISHAM, TAMIIA JAI (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:TAMIIA
Middle Name:JAI
Last Name:GRISHAM
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10537 MIDNIGHT GLEAM AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89129-3322
Mailing Address - Country:US
Mailing Address - Phone:702-328-1656
Mailing Address - Fax:
Practice Address - Street 1:10537 MIDNIGHT GLEAM AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89129-3322
Practice Address - Country:US
Practice Address - Phone:702-328-1656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-19
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV856876363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty