Provider Demographics
NPI:1801264064
Name:GRIMES, KENNETH LEWAYN (RN)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:LEWAYN
Last Name:GRIMES
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 S EWING RD
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301-0353
Mailing Address - Country:US
Mailing Address - Phone:207-683-0438
Mailing Address - Fax:270-683-4905
Practice Address - Street 1:314 S EWING RD
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-0353
Practice Address - Country:US
Practice Address - Phone:207-683-0438
Practice Address - Fax:270-683-4905
Is Sole Proprietor?:No
Enumeration Date:2015-09-04
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1090361163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse