Healthcare Provider Details

I. General information

NPI: 1558275719
Provider Name (Legal Business Name): GRACE MENDENHALL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2026
Last Update Date: 10/02/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88 DANBURY RD
WILTON CT
06897-4423
US

IV. Provider business mailing address

20 YORK ST
NEW HAVEN CT
06510-3220
US

V. Phone/Fax

Practice location:
  • Phone: 855-636-4637
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: