Healthcare Provider Details

I. General information

NPI: 1083124671
Provider Name (Legal Business Name): GRACE FAMILY PRACTICE CLINIC, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2017
Last Update Date: 10/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1716 PARR AVE STE D
DYERSBURG TN
38024-2074
US

IV. Provider business mailing address

1716 PARR AVE STE D
DYERSBURG TN
38024-2074
US

V. Phone/Fax

Practice location:
  • Phone: 731-288-0911
  • Fax: 731-288-0065
Mailing address:
  • Phone: 731-288-0911
  • Fax: 731-288-0065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD25289
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN13637
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD35727
License Number StateTN

VIII. Authorized Official

Name: MONIQUE CASEY-BOLDEN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 731-288-0911