Healthcare Provider Details

I. General information

NPI: 1811617863
Provider Name (Legal Business Name): BEAUTIFULLY GRACED LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2022
Last Update Date: 01/11/2024
Certification Date: 01/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2155 PALM BAY RD NE STE 7
PALM BAY FL
32905-2907
US

IV. Provider business mailing address

2155 PALM BAY RD NE STE 7
PALM BAY FL
32905-2907
US

V. Phone/Fax

Practice location:
  • Phone: 321-220-0862
  • Fax:
Mailing address:
  • Phone: 321-220-0862
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. STEPHANIE DENISE JERNIGHAN
Title or Position: FOUNDER
Credential:
Phone: 321-220-0862