Provider Demographics
NPI:1831414341
Name:GRACE, AIMEE RUSSELL (DO)
Entity type:Individual
Prefix:DR
First Name:AIMEE
Middle Name:RUSSELL
Last Name:GRACE
Suffix:
Gender:F
Credentials:DO
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Mailing Address - Street 1:PO BOX 1325
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40702-1325
Mailing Address - Country:US
Mailing Address - Phone:606-526-8131
Mailing Address - Fax:606-528-8661
Practice Address - Street 1:2 TRILLIUM WAY
Practice Address - Street 2:SUITE 306
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-8490
Practice Address - Country:US
Practice Address - Phone:606-526-4070
Practice Address - Fax:606-526-4072
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY03619207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100265930Medicaid
KYP01329276OtherRR MEDICARE
12628450OtherCAQH
12628450OtherCAQH