Provider Demographics
NPI:1639876519
Name:GRIMES, SAMANTHA (NP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:GRIMES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:MALONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:859-301-5652
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL VILLAGE DR
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3403
Practice Address - Country:US
Practice Address - Phone:859-301-5652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-13
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4000479363L00000X
OHAPRN.CNP.0030543363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner