Provider Demographics
NPI:1730848789
Name:GRADY, KIMBERLY (BSN, RN)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:GRADY
Suffix:
Gender:F
Credentials:BSN, RN
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:MALACINA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2550 S MAIN ST APT 6203
Mailing Address - Street 2:
Mailing Address - City:SOUTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84115-3083
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2550 S MAIN ST APT 6203
Practice Address - Street 2:
Practice Address - City:SOUTH SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84115-3083
Practice Address - Country:US
Practice Address - Phone:708-278-5602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-16
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10152046-3102163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral PracticeGroup - Single Specialty