Basic Information
| Provider Information | |||||||||
| NPI: | 1548670557 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRIME | ||||||||
| FirstName: | TRACI | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5777 | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378025777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8652462104 | ||||||||
| FaxNumber: | 8652462106 | ||||||||
| Practice Location | |||||||||
| Address1: | 907 E LAMAR ALEXANDER PKWY | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378045015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8659804897 | ||||||||
| FaxNumber: | 8659804896 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2014 | ||||||||
| LastUpdateDate: | 05/05/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 18689 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.