Basic Information
Provider Information | |||||||||
NPI: | 1982181061 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GRIMSLEY | ||||||||
FirstName: | MEGAN | ||||||||
MiddleName: | ANASTASIA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KENT | ||||||||
OtherFirstName: | MEGAN | ||||||||
OtherMiddleName: | ANASTASIA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 10 4TH AVE SE | ||||||||
Address2: |   | ||||||||
City: | GLENWOOD | ||||||||
State: | MN | ||||||||
PostalCode: | 563341820 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3206345157 | ||||||||
FaxNumber: | 3206342244 | ||||||||
Practice Location | |||||||||
Address1: | 600 PETERSON PKWY | ||||||||
Address2: |   | ||||||||
City: | NEW LONDON | ||||||||
State: | MN | ||||||||
PostalCode: | 562737823 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3203542222 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/23/2018 | ||||||||
LastUpdateDate: | 01/06/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/06/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 6003 | MN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | CNP6003 | 01 | MN | MN BOARD OF NURSING APRN LICENSE | OTHER |