Healthcare Provider Details

I. General information

NPI: 1801275144
Provider Name (Legal Business Name): GRACE E KNOWLES CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2015
Last Update Date: 02/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E CHICAGO AVE
CHICAGO IL
60611-2991
US

IV. Provider business mailing address

1507 OAK LAKE PARK RD
CORALVILLE IA
52241-1094
US

V. Phone/Fax

Practice location:
  • Phone: 800-543-7362
  • Fax:
Mailing address:
  • Phone: 505-250-4854
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080H0002X
TaxonomyPediatric Hospice and Palliative Medicine Physician
License NumberC145682
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberCNP-02374
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberC145682
License Number StateIA
# 4
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number209.18828
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: