Healthcare Provider Details

I. General information

NPI: 1134008212
Provider Name (Legal Business Name): GRACE JEAN GWALTNEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2025
Last Update Date: 09/02/2025
Certification Date: 09/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 SAINT FRANCIS DR
CAPE GIRARDEAU MO
63703-5049
US

IV. Provider business mailing address

890 VINES RD
COBDEN IL
62920-3609
US

V. Phone/Fax

Practice location:
  • Phone: 573-331-3000
  • Fax:
Mailing address:
  • Phone: 618-559-8833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: