Healthcare Provider Details

I. General information

NPI: 1871352732
Provider Name (Legal Business Name): LORI JEAN GRAMBOW RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2024
Last Update Date: 03/14/2024
Certification Date: 03/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 LEXINGTON AVE N
SHOREVIEW MN
55126-4003
US

IV. Provider business mailing address

4100 LEXINGTON AVE N
SHOREVIEW MN
55126-4003
US

V. Phone/Fax

Practice location:
  • Phone: 715-410-9385
  • Fax:
Mailing address:
  • Phone: 715-410-9385
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number1284472
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: