Provider Demographics
NPI:1083037758
Name:GRIMES, KELLYE MICHELLE (PA)
Entity Type:Individual
Prefix:
First Name:KELLYE
Middle Name:MICHELLE
Last Name:GRIMES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2665 SCRIPTURE ST
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76201-2302
Mailing Address - Country:US
Mailing Address - Phone:940-387-8763
Mailing Address - Fax:940-535-5901
Practice Address - Street 1:4430 E HIGHWAY 287 STE 100
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:TX
Practice Address - Zip Code:76065-5576
Practice Address - Country:US
Practice Address - Phone:972-723-5590
Practice Address - Fax:972-723-5592
Is Sole Proprietor?:No
Enumeration Date:2014-01-30
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
TXPA08921363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX342934YL7AMedicare PIN