MEDICARE: GRACE EVELYN COLLUPY CNM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367A00000X	Advanced Practice Midwife	9244471	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417140344
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRACE EVELYN COLLUPY CNM

Provider Business Mailing Address
First Line	:	719 RODEL CV
Second Line	:
City	:	LAKE MARY
State	:	FL
Zip	:	32746-5716
Country	:	US
Telephone Number	:	407-262-5710
Fax Number	:

Provider Business Practice Location Address
First Line	:	719 RODEL CV
Second Line	:
City	:	LAKE MARY
State	:	FL
Zip	:	32746-5716
Country	:	US
Telephone Number	:	407-262-5710
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2007
Last Update Date	:	01/20/2016

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