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General NPI Number Information
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NPI Number | 1306468483
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Entity Type | Individual
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Provider Name | KELLI ANN GRAMBEAU APRN
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Gender | Female
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Dates
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Enumeration Date | 05/12/2020
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Last Update Date | 05/12/2020
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Provider Practice Location Address
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Address Line | 110 E WALLACE AVE
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City | COEUR D ALENE
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State | ID
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Zip | 83814-2948
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Country | US
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Telephone | 208-853-0707
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Fax |
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Provider Business Mailing Address
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Address Line | 519 S 11TH ST
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City | COEUR D ALENE
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State | ID
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Zip | 83814-3805
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Country | US
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Telephone | 904-307-9195
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 60645
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License Number State | ID
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