MEDICARE: NANCY GRIMM PTA

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	225200000X	Physical Therapy Assistant

General Provider Information

NPI Number	:	1962994780
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NANCY GRIMM PTA

Provider Business Mailing Address
First Line	:	2578 N MARTIN LUTHER KING DR
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53212-2710
Country	:	US
Telephone Number	:	414-562-4386
Fax Number	:	414-562-4397

Provider Business Practice Location Address
First Line	:	2578 N MARTIN LUTHER KING DR
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53212-2710
Country	:	US
Telephone Number	:	414-562-4386
Fax Number	:	414-562-4397

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/06/2018
Last Update Date	:	06/06/2018

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