Healthcare Provider Details

I. General information

NPI: 1104536580
Provider Name (Legal Business Name): GRACE ADVANCED WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2022
Last Update Date: 11/28/2022
Certification Date: 11/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

543 E MAIN ST
HOHENWALD TN
38462-2007
US

IV. Provider business mailing address

543 E MAIN ST
HOHENWALD TN
38462-2007
US

V. Phone/Fax

Practice location:
  • Phone: 931-295-3547
  • Fax: 949-561-5674
Mailing address:
  • Phone: 931-295-3547
  • Fax: 949-561-5674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number
License Number State

VIII. Authorized Official

Name: SUSAN HENSLEY
Title or Position: OWNER/PROVIDER
Credential: APRN
Phone: 931-295-3547