Provider Demographics
NPI:1639409113
Name:GRIMES, AMY LYNNE (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:LYNNE
Last Name:GRIMES
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:LYNNE
Other - Last Name:LIDDICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1201 GRAMPIAN BLVD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-1900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 HIGH ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-3198
Practice Address - Country:US
Practice Address - Phone:570-321-3580
Practice Address - Fax:570-321-3581
Is Sole Proprietor?:No
Enumeration Date:2010-01-06
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP010528363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP00812893Medicare PIN