Healthcare Provider Details

I. General information

NPI: 1568232148
Provider Name (Legal Business Name): GRACE KATHERINE ANTHONY PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2024
Last Update Date: 01/04/2024
Certification Date: 01/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5006 COPPER AVE NE
ALBUQUERQUE NM
87108-1301
US

IV. Provider business mailing address

1601 CONESTOGA DR SE
ALBUQUERQUE NM
87123-4269
US

V. Phone/Fax

Practice location:
  • Phone: 505-268-7988
  • Fax:
Mailing address:
  • Phone: 216-612-4145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA22010
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: