Provider Demographics
NPI:1609414143
Name:GRIMM, AMBER (PA-C)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:GRIMM
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 1:1337 S INTERNATIONAL PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-1402
Mailing Address - Country:US
Mailing Address - Phone:407-878-0022
Mailing Address - Fax:888-815-1039
Practice Address - Street 1:1337 S INTERNATIONAL PKWY STE 1301
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-1402
Practice Address - Country:US
Practice Address - Phone:407-878-0022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-16
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9112838363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant