Healthcare Provider Details

I. General information

NPI: 1316586720
Provider Name (Legal Business Name): GRACE WATHEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2020
Last Update Date: 02/19/2026
Certification Date: 02/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5377 N 4400 W
CEDAR CITY UT
84721-5609
US

IV. Provider business mailing address

5377 N 4400 W
CEDAR CITY UT
84721-5609
US

V. Phone/Fax

Practice location:
  • Phone: 385-256-0022
  • Fax:
Mailing address:
  • Phone: 385-256-0022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number18517
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number11921654-1201
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: