Basic Information
| Provider Information | |||||||||
| NPI: | 1801363064 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRENFELL | ||||||||
| FirstName: | EMILY | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5410 MARYLAND WAY STE 300 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153775593 | ||||||||
| FaxNumber: | 6158108980 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 N EAGLE CREEK DR | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405091805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592679773 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2018 | ||||||||
| LastUpdateDate: | 10/25/2018 | ||||||||
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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 | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | KY | MEDICAID |