Provider Demographics
NPI:1487190112
Name:GRISSOM, KENDRA D (NP)
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:D
Last Name:GRISSOM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10777 HIGHWAY 412 W
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38351-6283
Mailing Address - Country:US
Mailing Address - Phone:731-968-5558
Mailing Address - Fax:731-968-5567
Practice Address - Street 1:10777 HIGHWAY 412 W
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:TN
Practice Address - Zip Code:38351-6283
Practice Address - Country:US
Practice Address - Phone:731-968-5558
Practice Address - Fax:731-968-5567
Is Sole Proprietor?:No
Enumeration Date:2017-01-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN22181363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics