Healthcare Provider Details

I. General information

NPI: 1770092314
Provider Name (Legal Business Name): GRACE ANYANGO OTIENO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2017
Last Update Date: 04/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2907 MOORGATE AVE
DURHAM NC
27704-6037
US

IV. Provider business mailing address

2907 MOORGATE AVE
DURHAM NC
27704-6037
US

V. Phone/Fax

Practice location:
  • Phone: 919-358-0979
  • Fax:
Mailing address:
  • Phone: 919-358-0979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number181012
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: