Healthcare Provider Details

I. General information

NPI: 1235818410
Provider Name (Legal Business Name): MATTIE MARIE GRIM APN-CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2023
Last Update Date: 10/22/2025
Certification Date: 10/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 RIDGE AVE
EVANSTON IL
60201-1700
US

IV. Provider business mailing address

2650 RIDGE AVE # 1223
EVANSTON IL
60201-1700
US

V. Phone/Fax

Practice location:
  • Phone: 847-570-2760
  • Fax: 847-570-2921
Mailing address:
  • Phone: 847-982-3175
  • Fax: 847-982-3394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209033399
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: