Healthcare Provider Details

I. General information

NPI: 1659655074
Provider Name (Legal Business Name): CHALLIS A. GRIMM ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2011
Last Update Date: 03/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

917 RINEHART RD SUITE 2041
LAKE MARY FL
32746-4802
US

IV. Provider business mailing address

4371 VERONICA S SHOEMAKER BLVD ATTN: CREDENTIALING
FORT MYERS FL
33916-2216
US

V. Phone/Fax

Practice location:
  • Phone: 407-804-6133
  • Fax: 321-283-4332
Mailing address:
  • Phone: 239-274-8200
  • Fax: 239-278-3350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP9176451
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: