Provider Demographics
NPI:1144562638
Name:GRIMES, KRISTEN ALEXIS (MS, RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:ALEXIS
Last Name:GRIMES
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:MISS
Other - First Name:KRISTEN
Other - Middle Name:ALEXIS
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, RD, LD
Mailing Address - Street 1:20 EPHRAIM TYLER WAY
Mailing Address - Street 2:
Mailing Address - City:KENNEBUNK
Mailing Address - State:ME
Mailing Address - Zip Code:04043-7361
Mailing Address - Country:US
Mailing Address - Phone:814-242-5812
Mailing Address - Fax:
Practice Address - Street 1:175 US ROUTE 1
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-9048
Practice Address - Country:US
Practice Address - Phone:207-396-7700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDI1130133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered