Basic Information
| Provider Information | |||||||||
| NPI: | 1912510850 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRISHAM | ||||||||
| FirstName: | DIXIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4311 11TH AVE NE STE 200 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981056367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2066164001 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1525 W VERMIJO AVE | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809044096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014257451 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2020 | ||||||||
| LastUpdateDate: | 08/29/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 2453-8564-6404 | 01 | UT | EMS-ID | OTHER |