Healthcare Provider Details

I. General information

NPI: 1912886755
Provider Name (Legal Business Name): GRACE NICHOLE DEYOUNG PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2025
Last Update Date: 10/23/2025
Certification Date: 10/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 NORTH STREET GRANVILLE MEDICAL CENTER
GRANVILLE NY
12832
US

IV. Provider business mailing address

100 PARK STREET GLENS FALLS HOSPITAL CREDENTIALING
GLENS FALLS NY
12801
US

V. Phone/Fax

Practice location:
  • Phone: 518-642-0612
  • Fax: 518-642-0693
Mailing address:
  • Phone: 518-926-5924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number034341
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: