Provider Demographics
NPI:1134155674
Name:GRELL, KIRSTEN (PA)
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:
Last Name:GRELL
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 1:5514 SEFTON AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21214-2339
Mailing Address - Country:US
Mailing Address - Phone:410-426-1576
Mailing Address - Fax:
Practice Address - Street 1:3333 N CALVERT ST
Practice Address - Street 2:SUITE 400
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-2867
Practice Address - Country:US
Practice Address - Phone:410-554-2871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1948363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZS36340Medicare UPIN