Provider Demographics
NPI:1255579124
Name:GRUNDY, KIMBERLY ANN (APN)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANN
Last Name:GRUNDY
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12A S BERYL RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72076-8708
Mailing Address - Country:US
Mailing Address - Phone:501-749-5446
Mailing Address - Fax:
Practice Address - Street 1:800 MARSHALL ST # 512-3
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72202-3510
Practice Address - Country:US
Practice Address - Phone:501-364-1479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-29
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA03184363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics