Basic Information
Provider Information | |||||||||
NPI: | 1033151139 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GRIMM | ||||||||
FirstName: | ANNA | ||||||||
MiddleName: | KATHLEEN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3181 SW SAM JACKSON PARK RD | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972393011 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5034941303 | ||||||||
FaxNumber: | 5033468021 | ||||||||
Practice Location | |||||||||
Address1: | 3181 SW SAM JACKSON PARK RD | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972393011 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5034941303 | ||||||||
FaxNumber: | 5033468021 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/12/2006 | ||||||||
LastUpdateDate: | 06/21/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 33115 | WV | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | COA.03700-NP | OH | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LA2100X | COA.03700-NP | OH | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LA2100X | 201501103NP-PP | OR | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LF0000X | 201501120NP-PP | OR | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 3810001991 | 05 | WV |   | MEDICAID | 0051782 | 05 | OH |   | MEDICAID | 1067391 | 01 | WV | WV WORK COMP | OTHER |