MEDICARE: KELLY MARIE GRIMES RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WR0006X	Registered Nurse First Assistant	658922	TX

General Provider Information

NPI Number	:	1629129051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY MARIE GRIMES RN

Provider Business Mailing Address
First Line	:	10070 WHEAT RIDGE DR
Second Line	:
City	:	FRISCO
State	:	TX
Zip	:	75034-4719
Country	:	US
Telephone Number	:	469-585-1649
Fax Number	:	468-287-2132

Provider Business Practice Location Address
First Line	:	10070 WHEAT RIDGE DR
Second Line	:
City	:	FRISCO
State	:	TX
Zip	:	75034-4719
Country	:	US
Telephone Number	:	469-585-1649
Fax Number	:	468-287-2132

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/14/2007
Last Update Date	:	09/04/2007

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