Provider Demographics
NPI:1912510850
Name:GRISHAM, DIXIE
Entity Type:Individual
Prefix:
First Name:DIXIE
Middle Name:
Last Name:GRISHAM
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 1:4311 11TH AVE NE STE 200
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-6367
Mailing Address - Country:US
Mailing Address - Phone:206-616-4001
Mailing Address - Fax:
Practice Address - Street 1:1525 W VERMIJO AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80904-4096
Practice Address - Country:US
Practice Address - Phone:801-425-7451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-29
Last Update Date:2020-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT2453-8564-6404OtherEMS-ID