Provider Demographics
NPI:1225590557
Name:GRIMES, COURTNEY ANN (AGNP)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:ANN
Last Name:GRIMES
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8970 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LISLE
Mailing Address - State:NY
Mailing Address - Zip Code:13797-1204
Mailing Address - Country:US
Mailing Address - Phone:607-435-6612
Mailing Address - Fax:
Practice Address - Street 1:169 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-4198
Practice Address - Country:US
Practice Address - Phone:607-798-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-04
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY645445163W00000X
NYF309184-01363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10312015Medicaid