Healthcare Provider Details

I. General information

NPI: 1700367471
Provider Name (Legal Business Name): GRACENIA JEROME
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2018
Last Update Date: 08/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

821 SW 3RD CT
DELRAY BEACH FL
33444
US

IV. Provider business mailing address

821 SW 3RD CT
DELRAY BEACH FL
33444-4436
US

V. Phone/Fax

Practice location:
  • Phone: 215-575-5073
  • Fax:
Mailing address:
  • Phone: 321-557-5507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA25566
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2110520
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number49065
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: