Provider Demographics
NPI:1902275787
Name:GRIME, SHANNON A (CNP)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:A
Last Name:GRIME
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:MISS
Other - First Name:SHANNON
Other - Middle Name:A
Other - Last Name:BURKHOLDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3400 OLENTANGY RIVER RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1523
Mailing Address - Country:US
Mailing Address - Phone:614-754-5500
Mailing Address - Fax:614-457-9519
Practice Address - Street 1:3400 OLENTANGY RIVER RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43202-1523
Practice Address - Country:US
Practice Address - Phone:614-754-5500
Practice Address - Fax:614-457-9519
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-22
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH312107163W00000X
OHCOA.18361-NP363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH13586175OtherCAQH