Provider Demographics
NPI:1427709054
Name:GRIZZLE, TASHUA LASHUN (RN)
Entity type:Individual
Prefix:
First Name:TASHUA
Middle Name:LASHUN
Last Name:GRIZZLE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4131 MERLE CT
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30252-8125
Mailing Address - Country:US
Mailing Address - Phone:678-772-0830
Mailing Address - Fax:
Practice Address - Street 1:4131 MERLE CT
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30252-8125
Practice Address - Country:US
Practice Address - Phone:678-772-0830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-14
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GANHA004969376G00000X
GARN29755163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator
No376G00000XNursing Service Related ProvidersNursing Home Administrator