Healthcare Provider Details

I. General information

NPI: 1619163110
Provider Name (Legal Business Name): SARAH ELIZABETH GRIMM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2007
Last Update Date: 12/03/2020
Certification Date: 12/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3084 LAKECREST CIR
LEXINGTON KY
40513-1706
US

IV. Provider business mailing address

3084 LAKECREST CIR
LEXINGTON KY
40513-1706
US

V. Phone/Fax

Practice location:
  • Phone: 859-219-6440
  • Fax: 859-219-6449
Mailing address:
  • Phone: 859-219-6440
  • Fax: 859-219-6449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA1029
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: