Provider Demographics
NPI:1194483297
Name:GRIMALDI, JOHANNA VICTORIA (NP)
Entity type:Individual
Prefix:MISS
First Name:JOHANNA
Middle Name:VICTORIA
Last Name:GRIMALDI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JOHANNA
Other - Middle Name:VICTORIA
Other - Last Name:RHEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1600 HARBOR BLVD APT 1415W
Mailing Address - Street 2:
Mailing Address - City:WEEHAWKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07086-6881
Mailing Address - Country:US
Mailing Address - Phone:716-491-5594
Mailing Address - Fax:
Practice Address - Street 1:1468 MADISON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6508
Practice Address - Country:US
Practice Address - Phone:212-241-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-06
Last Update Date:2023-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR20140300163W00000X
NY748106163W00000X
NYF432189363LA2100X
NY432189363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY07250333Medicaid