Healthcare Provider Details

I. General information

NPI: 1609423656
Provider Name (Legal Business Name): LYNN CHERYL GRISHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2019
Last Update Date: 08/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5616 BENTWOOD TRL NE
ALBUQUERQUE NM
87109-3207
US

IV. Provider business mailing address

5616 BENTWOOD TRL NE
ALBUQUERQUE NM
87109-3207
US

V. Phone/Fax

Practice location:
  • Phone: 505-856-5276
  • Fax:
Mailing address:
  • Phone: 505-856-5276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number3747A0650X
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: