Provider Demographics
NPI:1013408806
Name:GRIM, AMOS RICHARD (NP)
Entity Type:Individual
Prefix:
First Name:AMOS
Middle Name:RICHARD
Last Name:GRIM
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 MEDICAL DR STE D101
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-8905
Mailing Address - Country:US
Mailing Address - Phone:801-683-1062
Mailing Address - Fax:
Practice Address - Street 1:5974 FASHION POINT DR STE 140
Practice Address - Street 2:
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4838
Practice Address - Country:US
Practice Address - Phone:801-683-1062
Practice Address - Fax:801-295-5537
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-29
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1180631-8900363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty