Healthcare Provider Details

I. General information

NPI: 1457231656
Provider Name (Legal Business Name): GRACE VANTHUYNE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2025
Last Update Date: 09/08/2025
Certification Date: 09/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 OLD YORK RD
PHILADELPHIA PA
19141-3018
US

IV. Provider business mailing address

1241 ANDERS RD
LANSDALE PA
19446-4816
US

V. Phone/Fax

Practice location:
  • Phone: 215-456-7890
  • Fax:
Mailing address:
  • Phone: 267-844-1356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA066996
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: