Healthcare Provider Details

I. General information

NPI: 1720119522
Provider Name (Legal Business Name): KATHY A GRACE PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 10/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

839 S PUTNAM ST
WILLIAMSTON MI
48895-1623
US

IV. Provider business mailing address

3955 PATIENT CARE WAY STE A
LANSING MI
48911-4271
US

V. Phone/Fax

Practice location:
  • Phone: 517-655-3515
  • Fax: 517-655-3743
Mailing address:
  • Phone: 517-374-7600
  • Fax: 517-374-9042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number003250
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: