Healthcare Provider Details

I. General information

NPI: 1609759992
Provider Name (Legal Business Name): HALEY TRIVETTE GRIMM FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2025
Last Update Date: 10/08/2025
Certification Date: 10/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6301 STADIUM DR
CLEMMONS NC
27012-8766
US

IV. Provider business mailing address

6301 STADIUM DR STE 500
CLEMMONS NC
27012-8766
US

V. Phone/Fax

Practice location:
  • Phone: 336-428-6630
  • Fax:
Mailing address:
  • Phone: 336-428-6630
  • Fax: 336-766-8909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5022828
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: