Healthcare Provider Details

I. General information

NPI: 1801131529
Provider Name (Legal Business Name): TALIA M GRIM CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2012
Last Update Date: 12/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 W LANCASTER AVE
PAOLI PA
19301-1763
US

IV. Provider business mailing address

255 W MICHIGAN AVE PO BOX 1123
JACKSON MI
49201-2218
US

V. Phone/Fax

Practice location:
  • Phone: 610-648-1000
  • Fax: 517-787-2922
Mailing address:
  • Phone: 800-242-1131
  • Fax: 517-787-7075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN578703
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: