Healthcare Provider Details

I. General information

NPI: 1003710880
Provider Name (Legal Business Name): MARSHA L GRACE CCHW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 STATE ST
ERIE PA
16501-1914
US

IV. Provider business mailing address

1202 STATE ST
ERIE PA
16501-1914
US

V. Phone/Fax

Practice location:
  • Phone: 814-455-7222
  • Fax: 814-453-4857
Mailing address:
  • Phone: 814-454-4530
  • Fax: 814-453-4857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number24310
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: