Healthcare Provider Details

I. General information

NPI: 1104972108
Provider Name (Legal Business Name): DOUGLAS NATHANAEL GRIMES CNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138 SALVADORE DR
CRESTVIEW FL
32536-1802
US

IV. Provider business mailing address

138 SALVADORE DR
CRESTVIEW FL
32536-1802
US

V. Phone/Fax

Practice location:
  • Phone: 850-682-2433
  • Fax:
Mailing address:
  • Phone: 850-682-2433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberCNA 8761
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: