Provider Demographics
NPI:1043928542
Name:GRIMES, PAMELA SUE (RN)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:SUE
Last Name:GRIMES
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 ROLLIE MOORE DR
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:IL
Mailing Address - Zip Code:62946-2351
Mailing Address - Country:US
Mailing Address - Phone:618-252-6595
Mailing Address - Fax:
Practice Address - Street 1:608 ROLLIE MOORE DR
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:IL
Practice Address - Zip Code:62946-2351
Practice Address - Country:US
Practice Address - Phone:618-252-6595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1084074163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse