Healthcare Provider Details

I. General information

NPI: 1033474580
Provider Name (Legal Business Name): JOHANNA MARIE GRASSHAM RN, CDE, BC-ADM, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2012
Last Update Date: 07/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 EUBANK BLVD SE BLDG 832
ALBUQUERQUE NM
87123-3453
US

IV. Provider business mailing address

1515 EUBANK BLVD SE BLDG 832
ALBUQUERQUE NM
87123-3453
US

V. Phone/Fax

Practice location:
  • Phone: 505-844-4237
  • Fax:
Mailing address:
  • Phone: 505-844-4237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR49987
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number2091-0361
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number56889
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: