Healthcare Provider Details

I. General information

NPI: 1932669553
Provider Name (Legal Business Name): GRACE WALTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2019
Last Update Date: 08/12/2022
Certification Date: 08/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4414 BENNING RD NE
WASHINGTON DC
20019-4555
US

IV. Provider business mailing address

4151 BLADENSBURG RD
COLMAR MANOR MD
20722-1928
US

V. Phone/Fax

Practice location:
  • Phone: 202-469-4699
  • Fax:
Mailing address:
  • Phone: 301-699-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD210002182
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: