Basic Information
| Provider Information | |||||||||
| NPI: | 1629336979 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRINNELL | ||||||||
| FirstName: | LILLAH | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 305 CARPENTER RD | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805254248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706633500 | ||||||||
| FaxNumber: | 9706631180 | ||||||||
| Practice Location | |||||||||
| Address1: | 214 E 23RD ST | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820013748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076342273 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2012 | ||||||||
| LastUpdateDate: | 11/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 990372 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 44363 | WY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | NP-990372 | 01 | CO | COLORADO LICENSE NUMBER | OTHER |