Provider Demographics
NPI:1730797077
Name:GRIMES-MALLARD, KRISTIE MICHELLE (RN)
Entity type:Individual
Prefix:
First Name:KRISTIE
Middle Name:MICHELLE
Last Name:GRIMES-MALLARD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 HOWE ST UNIT 1
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02125-2143
Mailing Address - Country:US
Mailing Address - Phone:617-828-9941
Mailing Address - Fax:
Practice Address - Street 1:45 DIMOCK ST
Practice Address - Street 2:
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119-1208
Practice Address - Country:US
Practice Address - Phone:617-442-8800
Practice Address - Fax:617-541-8334
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-22
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2335640163W00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110164451AMedicaid