Healthcare Provider Details

I. General information

NPI: 1639028699
Provider Name (Legal Business Name): GRACE KATHLEEN BONTRAGER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2026
Last Update Date: 02/23/2026
Certification Date: 02/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19450 DEERFIELD AVE STE 460
LEESBURG VA
20176-6840
US

IV. Provider business mailing address

1715 15TH ST NW APT 51
WASHINGTON DC
20009-3878
US

V. Phone/Fax

Practice location:
  • Phone: 571-707-8522
  • Fax:
Mailing address:
  • Phone: 571-707-8522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number0024196126
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: