Healthcare Provider Details

I. General information

NPI: 1104146133
Provider Name (Legal Business Name): JOLIETTE NICOLE GRACE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JOLIETTE NICOLE BARNUM MD

II. Dates (important events)

Enumeration Date: 06/01/2010
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HERLONG AVE S STE G
ROCK HILL SC
29732-1182
US

IV. Provider business mailing address

13111 BRIDGEPORT XING
BRADENTON FL
34211-4002
US

V. Phone/Fax

Practice location:
  • Phone: 803-909-6300
  • Fax: 803-909-6310
Mailing address:
  • Phone: 573-703-5663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number93469
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME133013
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberME133013
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: