Basic Information
Provider Information | |||||||||
NPI: | 1336222926 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GRIGG | ||||||||
FirstName: | DEBORAH | ||||||||
MiddleName: | W | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CNM | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2680 ABERDEEN BLVD | ||||||||
Address2: | SUITE A | ||||||||
City: | GASTONIA | ||||||||
State: | NC | ||||||||
PostalCode: | 280540637 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7048652229 | ||||||||
FaxNumber: | 7048652811 | ||||||||
Practice Location | |||||||||
Address1: | 2680 ABERDEEN BLVD | ||||||||
Address2: | SUITE A | ||||||||
City: | GASTONIA | ||||||||
State: | NC | ||||||||
PostalCode: | 280540637 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7048652229 | ||||||||
FaxNumber: | 7048652811 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/24/2006 | ||||||||
LastUpdateDate: | 01/20/2012 | ||||||||
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 | 367A00000X | CMN176 | NC | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |   |
ID Information
ID | Type | State | Issuer | Description | MG0255756 | 01 | NC | DEA NUMBER | OTHER |