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General NPI Number Information
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NPI Number | 1902314958
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Entity Type | Individual
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Provider Name | JOHN GRIMSHAW FNP-C
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Gender | Male
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Dates
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Enumeration Date | 01/11/2018
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Last Update Date | 01/11/2018
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Provider Practice Location Address
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Address Line | 7601 W JEFFERSON BLVD
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City | FORT WAYNE
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State | IN
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Zip | 46804-4133
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Country | US
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Telephone | 800-566-5659
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Fax |
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Provider Business Mailing Address
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Address Line | 14394 US HIGHWAY 6
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City | SYRACUSE
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State | IN
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Zip | 46567-9207
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Country | US
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Telephone | 574-529-1212
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Fax | 574-528-5095
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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 | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 28202216A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | PENDING
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License Number State | IN
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