1720223605 NPI number — MRS. KELLY E POWELL-GRIM APRN-C

Table of content: MRS. KELLY E POWELL-GRIM APRN-C (NPI 1720223605)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720223605 NPI number — MRS. KELLY E POWELL-GRIM APRN-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POWELL-GRIM
Provider First Name:
KELLY
Provider Middle Name:
E
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APRN-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SANCHEZ
Provider Other First Name:
KELLY
Provider Other Middle Name:
E
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
ARNP-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1720223605
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/16/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9488 HERNANDO RIDGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEEKI WACHEE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34613-6446
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-819-2945
Provider Business Mailing Address Fax Number:
727-819-2970

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14100 FIVAY RD STE 265
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUDSON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34667-7151
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-819-2945
Provider Business Practice Location Address Fax Number:
727-819-2970
Provider Enumeration Date:
12/08/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  3085712 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 023965429 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 112198900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com