Provider Demographics
NPI:1235435835
Name:GRILLO, KIRSTEN DEEDS (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KIRSTEN
Middle Name:DEEDS
Last Name:GRILLO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 KENNEDY DR
Mailing Address - Street 2:SUITE L201
Mailing Address - City:TORRINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06790-3060
Mailing Address - Country:US
Mailing Address - Phone:860-806-0557
Mailing Address - Fax:
Practice Address - Street 1:333 KENNEDY DR
Practice Address - Street 2:SUITE L201
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-3060
Practice Address - Country:US
Practice Address - Phone:860-806-0557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-31
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA4125363A00000X
CT2558363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant