Healthcare Provider Details

I. General information

NPI: 1568002160
Provider Name (Legal Business Name): AMAZING GRACE HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2020
Last Update Date: 02/11/2022
Certification Date: 02/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 SNELLING AVE N STE A
SAINT PAUL MN
55104-5585
US

IV. Provider business mailing address

625 SNELLING AVE N STE A
SAINT PAUL MN
55104-5585
US

V. Phone/Fax

Practice location:
  • Phone: 952-288-9921
  • Fax:
Mailing address:
  • Phone: 763-381-4188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: VICTOR DAVIS
Title or Position: CO-OWNER/NURSE PRACTITIONER
Credential:
Phone: 952-288-9921