Provider Demographics
NPI:1306148820
Name:GRIDER, NICHOLAS JON (LPN)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:JON
Last Name:GRIDER
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3113 N DOUSMAN ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-2245
Mailing Address - Country:US
Mailing Address - Phone:414-640-7656
Mailing Address - Fax:414-374-5364
Practice Address - Street 1:3113 N DOUSMAN ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-2245
Practice Address - Country:US
Practice Address - Phone:414-640-7656
Practice Address - Fax:414-374-5364
Is Sole Proprietor?:No
Enumeration Date:2010-12-04
Last Update Date:2010-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI313012-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse