Healthcare Provider Details

I. General information

NPI: 1902275787
Provider Name (Legal Business Name): SHANNON A GRIME CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MISS SHANNON A BURKHOLDER

II. Dates (important events)

Enumeration Date: 09/22/2015
Last Update Date: 11/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 OLENTANGY RIVER RD
COLUMBUS OH
43202-1523
US

IV. Provider business mailing address

3400 OLENTANGY RIVER RD
COLUMBUS OH
43202-1523
US

V. Phone/Fax

Practice location:
  • Phone: 614-754-5500
  • Fax: 614-457-9519
Mailing address:
  • Phone: 614-754-5500
  • Fax: 614-457-9519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberCOA.18361-NP
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number312107
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: