Healthcare Provider Details

I. General information

NPI: 1710735634
Provider Name (Legal Business Name): GRACE ANN STUKEL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2024
Last Update Date: 11/05/2025
Certification Date: 11/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

676 N SAINT CLAIR ST STE 650
CHICAGO IL
60611-2929
US

IV. Provider business mailing address

676 N SAINT CLAIR ST STE 650
CHICAGO IL
60611-2929
US

V. Phone/Fax

Practice location:
  • Phone: 312-926-0159
  • Fax: 312-695-4955
Mailing address:
  • Phone: 312-926-0159
  • Fax: 312-695-4955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085011344
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: