Healthcare Provider Details

I. General information

NPI: 1801452172
Provider Name (Legal Business Name): GRACE TRINIDAD MCCORMICK REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: GRACE GONZALES TRINIDAD

II. Dates (important events)

Enumeration Date: 05/13/2019
Last Update Date: 05/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 W SEMANDS ST
CONROE TX
77301-1867
US

IV. Provider business mailing address

2302 KEEGAN HOLLOW LN
SPRING TX
77386-3325
US

V. Phone/Fax

Practice location:
  • Phone: 936-756-5598
  • Fax: 936-756-5974
Mailing address:
  • Phone: 281-904-5933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number948573
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: