Provider Demographics
NPI:1447553029
Name:GRAYSON, KIMBERLY JOAN
Entity type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:JOAN
Last Name:GRAYSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 TAMMY DR
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-3669
Mailing Address - Country:US
Mailing Address - Phone:407-430-7483
Mailing Address - Fax:
Practice Address - Street 1:300 TAMMY DR
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-3669
Practice Address - Country:US
Practice Address - Phone:407-430-7483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-21
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA11181174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist