Healthcare Provider Details

I. General information

NPI: 1669756813
Provider Name (Legal Business Name): NICHOLE SUZANNE GRIMM NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2011
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

423 N 3RD AVE STE 201
SANDPOINT ID
83864-1511
US

IV. Provider business mailing address

PO BOX 1343
SANDPOINT ID
83864-0863
US

V. Phone/Fax

Practice location:
  • Phone: 208-263-2221
  • Fax:
Mailing address:
  • Phone: 208-263-1441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP-1113A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: