Provider Demographics
NPI:1437346194
Name:GRIMM, NICOLE YVONNE (PTA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:YVONNE
Last Name:GRIMM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6405 METCALF AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66202-4084
Mailing Address - Country:US
Mailing Address - Phone:913-831-2721
Mailing Address - Fax:
Practice Address - Street 1:6405 METCALF AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66202-3927
Practice Address - Country:US
Practice Address - Phone:913-831-2721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-26
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
KS225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No174400000XOther Service ProvidersSpecialist