Healthcare Provider Details

I. General information

NPI: 1023869112
Provider Name (Legal Business Name): MARY PAYTON GRIMMETT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2024
Last Update Date: 03/28/2024
Certification Date: 03/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17240 HEARTBEAT CIRCLE
COVINGTON LA
70435
US

IV. Provider business mailing address

258 HIGHWAY 906
MONTEREY LA
71354-4002
US

V. Phone/Fax

Practice location:
  • Phone: 985-867-3073
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: