Provider Demographics
NPI:1932684727
Name:GRIMSHAW, KELLY (BSN, RN, CDE)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GRIMSHAW
Suffix:
Gender:F
Credentials:BSN, RN, CDE
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 557
Mailing Address - Street 2:
Mailing Address - City:ROSEBUD
Mailing Address - State:SD
Mailing Address - Zip Code:57570-0557
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 SOLDIER CREEK DR
Practice Address - Street 2:
Practice Address - City:ROSEBUD
Practice Address - State:SD
Practice Address - Zip Code:57570-8502
Practice Address - Country:US
Practice Address - Phone:605-747-0649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-27
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR043498163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator