Healthcare Provider Details

I. General information

NPI: 1083135875
Provider Name (Legal Business Name): GRACE MARGARET MICHEL FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: GRACE MARGARET FALLON RN

II. Dates (important events)

Enumeration Date: 06/30/2017
Last Update Date: 06/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 INTREPID LN
SYRACUSE NY
13205-2548
US

IV. Provider business mailing address

3 BARBARA LN
CAMILLUS NY
13031-2204
US

V. Phone/Fax

Practice location:
  • Phone: 315-469-8700
  • Fax: 315-469-6789
Mailing address:
  • Phone: 315-427-9181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberF3418861
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: