=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902435969
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | COREY MICHAEL GRINDO FNP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2020
-----------------------------------------------------
Last Update Date | 11/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11491 US 70 BUS HWY W
-----------------------------------------------------
City | CLAYTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27520-2207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-550-2484
-----------------------------------------------------
Fax | 919-550-7059
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5311 JESSIP ST APT 435
-----------------------------------------------------
City | MORRISVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27560-5217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-239-9555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 5013047
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------