Provider Demographics
NPI:1912771486
Name:GRISHAM, DONNA
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:GRISHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 497
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:AR
Mailing Address - Zip Code:72006-0497
Mailing Address - Country:US
Mailing Address - Phone:870-472-5348
Mailing Address - Fax:870-301-2092
Practice Address - Street 1:65 S THOMAS ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4352
Practice Address - Country:US
Practice Address - Phone:662-350-7010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-14
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS905951363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily