=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831165547
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GRISELLE SHERMAN M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2006
-----------------------------------------------------
Last Update Date | 12/04/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | BLDG 9040 JACKSON AVENUE
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98431-5109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-968-5068
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11610 TERRY LAKE RD SW
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98498-2714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-445-8260
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | J1135
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------