Healthcare Provider Details

I. General information

NPI: 1154691566
Provider Name (Legal Business Name): GRACEVILLE FAMILY MEDICINE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2012
Last Update Date: 10/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5239 BROWN ST
GRACEVILLE FL
32440-2513
US

IV. Provider business mailing address

5239 BROWN ST
GRACEVILLE FL
32440-2513
US

V. Phone/Fax

Practice location:
  • Phone: 850-360-4909
  • Fax: 850-360-4911
Mailing address:
  • Phone: 850-360-4909
  • Fax: 850-360-4911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9321958
License Number StateFL

VIII. Authorized Official

Name: LUCINDA W COLLINS
Title or Position: OWNER
Credential: ARNP
Phone: 850-360-4909