Provider Demographics
NPI:1598276057
Name:GRIMM, TAYLORE MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:TAYLORE
Middle Name:MARIE
Last Name:GRIMM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6522 ORANGE PLANK DR
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-3394
Mailing Address - Country:US
Mailing Address - Phone:219-575-1011
Mailing Address - Fax:
Practice Address - Street 1:979 E 3RD ST STE C-520
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2136
Practice Address - Country:US
Practice Address - Phone:423-778-5661
Practice Address - Fax:423-778-5664
Is Sole Proprietor?:No
Enumeration Date:2017-10-23
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3397208G00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3397OtherSTATE LICENSE NUMBER