Healthcare Provider Details

I. General information

NPI: 1568437135
Provider Name (Legal Business Name): SALLY L GRACE A.P.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 08/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

614 E EMMA AVE SUITE 300
SPRINGDALE AR
72764-4634
US

IV. Provider business mailing address

614 E EMMA AVE SUITE 300
SPRINGDALE AR
72764-4634
US

V. Phone/Fax

Practice location:
  • Phone: 479-751-7417
  • Fax: 479-751-4898
Mailing address:
  • Phone: 479-751-7417
  • Fax: 479-751-4898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberA01038
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: