Provider Demographics
NPI:1265695530
Name:GRIMMER, KELSEY (PA)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:GRIMMER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 N WESTMORELAND RD
Mailing Address - Street 2:STE 222
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1674
Mailing Address - Country:US
Mailing Address - Phone:920-791-1347
Mailing Address - Fax:
Practice Address - Street 1:900 N WESTMORELAND RD
Practice Address - Street 2:STE 222
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1674
Practice Address - Country:US
Practice Address - Phone:920-791-1347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-08
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2303363AM0700X
IL085004128363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical