Basic Information
| Provider Information | |||||||||
| NPI: | 1043276868 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRISHAM | ||||||||
| FirstName: | DANA | ||||||||
| MiddleName: | JEAN | ||||||||
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| Credential: | R.N. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 635 W COLLEGE ST | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356305313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567643431 | ||||||||
| FaxNumber: | 2567652036 | ||||||||
| Practice Location | |||||||||
| Address1: | 635 W COLLEGE ST | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356305313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567643431 | ||||||||
| FaxNumber: | 2567652036 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 1-090029 | AL | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 515-24607 | 01 | AL | BCBS OF AL | OTHER |