MEDICARE: ANNIE GRUMMEL, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1407321136
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANNIE GRUMMEL, LLC

Provider Business Mailing Address
First Line	:	758 NW POWHATAN TER
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97210-2731
Country	:	US
Telephone Number	:	503-706-9791
Fax Number	:

Provider Business Practice Location Address
First Line	:	2187 SW MAIN ST STE 101
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97205-1123
Country	:	US
Telephone Number	:	503-894-9810
Fax Number	:

Authorized Official
Title or Position	:	PRACTITIONER
Name	:	ANN GRUMMEL WARD
Credential	:	PMHNP
Telephone Number	:	503-894-9810

Provider Enumeration Date	:	10/09/2018
Last Update Date	:	05/02/2022

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