Provider Demographics
NPI:1578561262
Name:GRIMES, BRENT ALAN (NP-C)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:ALAN
Last Name:GRIMES
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1740
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38835-1740
Mailing Address - Country:US
Mailing Address - Phone:662-284-8565
Mailing Address - Fax:662-594-8366
Practice Address - Street 1:3037 CORDER DR
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-6216
Practice Address - Country:US
Practice Address - Phone:662-284-8565
Practice Address - Fax:662-594-8366
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN16792363L00000X
TNAPN0000016792363LF0000X
MS810467363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS004252075Medicaid
TN3675100Medicare ID - Type Unspecified
TN93692OtherBLUE CROSS BLUE SHIELD