Healthcare Provider Details

I. General information

NPI: 1013428564
Provider Name (Legal Business Name): GRACE LIOUE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2017
Last Update Date: 05/16/2022
Certification Date: 05/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 E 38TH ST FL 13
NEW YORK NY
10016-2708
US

IV. Provider business mailing address

8 SPRUCE ST APT 19D
NEW YORK NY
10038-5211
US

V. Phone/Fax

Practice location:
  • Phone: 212-598-6500
  • Fax: 212-598-6689
Mailing address:
  • Phone: 732-372-9477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number341965
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: