Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | MD12296 | RI |
Y | 2080A0000X | Adolescent Medicine | MD12296 | RI |
NPI | 1063618783 |
---|---|
Provider Name | Kristin A Grimes |
First Address | Cumberland, RI 02864-3833 |
Second Address | Cumberland, RI 02864-3833 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/06/2007 |
Last Update Date | 08/02/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
FC0236213 | DEA (01) | RI |
MD12296 | MEDICAL LICENSE (01) | RI |