Healthcare Provider Details

I. General information

NPI: 1679934632
Provider Name (Legal Business Name): JOHNNA GRIMES AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2016
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 WESTOVER CIR STE B
MADISON AL
35758-4910
US

IV. Provider business mailing address

101 WESTOVER CIR STE B
MADISON AL
35758-4910
US

V. Phone/Fax

Practice location:
  • Phone: 256-325-3800
  • Fax:
Mailing address:
  • Phone: 256-325-3800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number1-126764
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: