Provider Demographics
NPI:1306468483
Name:GRAMBEAU, KELLI ANN (APRN)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:ANN
Last Name:GRAMBEAU
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 S 11TH ST
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-3805
Mailing Address - Country:US
Mailing Address - Phone:904-307-9195
Mailing Address - Fax:
Practice Address - Street 1:110 E WALLACE AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2948
Practice Address - Country:US
Practice Address - Phone:208-853-0707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-12
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID60645363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily