Healthcare Provider Details

I. General information

NPI: 1053063651
Provider Name (Legal Business Name): GRACE THOMPSON PARK CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2022
Last Update Date: 04/12/2022
Certification Date: 01/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5200 HARRY HINES BLVD
DALLAS TX
75235-7709
US

IV. Provider business mailing address

906 KENSINGTON DR
DUNCANVILLE TX
75137-2138
US

V. Phone/Fax

Practice location:
  • Phone: 214-590-8000
  • Fax:
Mailing address:
  • Phone: 281-638-1877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number1069315
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: