Provider Demographics
NPI:1104972108
Name:GRIMES, DOUGLAS NATHANAEL (CNA)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:NATHANAEL
Last Name:GRIMES
Suffix:
Gender:M
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 SALVADORE DR
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-1802
Mailing Address - Country:US
Mailing Address - Phone:850-682-2433
Mailing Address - Fax:
Practice Address - Street 1:138 SALVADORE DR
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-1802
Practice Address - Country:US
Practice Address - Phone:850-682-2433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCNA 8761390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program