Healthcare Provider Details

I. General information

NPI: 1164867735
Provider Name (Legal Business Name): SHAUNA MARIE GRADY D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2013
Last Update Date: 09/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2923 GINNALA DR
LOVELAND CO
80538-2702
US

IV. Provider business mailing address

2923 GINNALA DR
LOVELAND CO
80538-2702
US

V. Phone/Fax

Practice location:
  • Phone: 970-669-6660
  • Fax:
Mailing address:
  • Phone: 970-669-6660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberDR0056675
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: