Healthcare Provider Details

I. General information

NPI: 1811658008
Provider Name (Legal Business Name): GRACE WELLNESS & AESTHETICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2022
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 SAINT JOHNS AVE
PALATKA FL
32177-4724
US

IV. Provider business mailing address

417 SAINT JOHNS AVE
PALATKA FL
32177-4724
US

V. Phone/Fax

Practice location:
  • Phone: 352-719-0700
  • Fax: 352-719-0719
Mailing address:
  • Phone: 352-719-0700
  • Fax: 342-719-0719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: LEAMARIE LORD
Title or Position: OWNER
Credential: FNP
Phone: 352-421-5736