MEDICARE: MYRANDA GRACE

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	164W00000X	Licensed Practical Nurse	LPN105798	GA

General Provider Information

NPI Number	:	1528924214
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MYRANDA GRACE

Provider Business Mailing Address
First Line	:	3800 AUGUSTINE PL
Second Line	:
City	:	REX
State	:	GA
Zip	:	30273-5822
Country	:	US
Telephone Number	:	813-727-9377
Fax Number	:

Provider Business Practice Location Address
First Line	:	3800 AUGUSTINE PL
Second Line	:
City	:	REX
State	:	GA
Zip	:	30273-5822
Country	:	US
Telephone Number	:	813-727-9377
Fax Number	:

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

Provider Enumeration Date	:	12/26/2025
Last Update Date	:	12/26/2025

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Directions to “ MYRANDA GRACE ” Practice Location

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