Provider Demographics
NPI:1033474580
Name:GRASSHAM, JOHANNA MARIE (RN, CDE, BC-ADM, CNP)
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:MARIE
Last Name:GRASSHAM
Suffix:
Gender:F
Credentials:RN, CDE, BC-ADM, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 EUBANK BLVD SE BLDG 832
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87123-3453
Mailing Address - Country:US
Mailing Address - Phone:505-844-4237
Mailing Address - Fax:
Practice Address - Street 1:1515 EUBANK BLVD SE BLDG 832
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87123-3453
Practice Address - Country:US
Practice Address - Phone:505-844-4237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR49987163W00000X
NM2091-0361163WD0400X
NM56889363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator