Healthcare Provider Details

I. General information

NPI: 1821702663
Provider Name (Legal Business Name): AMAZING GRACE PRIMARY CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2023
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 E PARK AVE
CHIEFLAND FL
32626-0901
US

IV. Provider business mailing address

110 E PARK AVE
CHIEFLAND FL
32626-0901
US

V. Phone/Fax

Practice location:
  • Phone: 352-949-0478
  • Fax: 352-752-3305
Mailing address:
  • Phone: 352-949-0478
  • Fax: 352-754-3305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SALLY MARTINEZ
Title or Position: CEO
Credential: FNP-BC, DNP
Phone: 352-339-8981