Healthcare Provider Details

I. General information

NPI: 1356657084
Provider Name (Legal Business Name): JANE MARIE GRIMBERG CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2010
Last Update Date: 06/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 WYOMING ST
DAYTON OH
45409-2731
US

IV. Provider business mailing address

1 WYOMING ST
DAYTON OH
45409-2722
US

V. Phone/Fax

Practice location:
  • Phone: 937-223-4461
  • Fax: 937-449-7603
Mailing address:
  • Phone: 937-208-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN191859-COA1
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: