Provider Demographics
NPI:1497104301
Name:GRIGSBY, KENNETH (CRNA)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:GRIGSBY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 OAK CREEK RD APT D128
Mailing Address - Street 2:
Mailing Address - City:RIVER RIDGE
Mailing Address - State:LA
Mailing Address - Zip Code:70123-5837
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1421 N 7TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47807-1005
Practice Address - Country:US
Practice Address - Phone:812-231-4608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-10
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN514266367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered