Provider Demographics
NPI:1316905045
Name:GRIMM, CHARLOTTE L (APRN)
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:L
Last Name:GRIMM
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 1:224 HAILI ST STE B
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-2975
Mailing Address - Country:US
Mailing Address - Phone:808-961-4072
Mailing Address - Fax:808-961-5678
Practice Address - Street 1:1178B KINOOLE ST
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-4133
Practice Address - Country:US
Practice Address - Phone:808-969-1427
Practice Address - Fax:808-961-4909
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAPRN 789363LF0000X
HIRN43876163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIQ757716Medicare UPIN
HIH102085Medicare PIN
HIH102086Medicare PIN
HIH102088Medicare PIN
HIH102087Medicare PIN