Healthcare Provider Details

I. General information

NPI: 1689774978
Provider Name (Legal Business Name): GRACE E CARROLL CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 BUSINESS PARK DR
VIRGINIA BEACH VA
23462-6523
US

IV. Provider business mailing address

536 NEW JERSEY AVE
NORFOLK VA
23508-2719
US

V. Phone/Fax

Practice location:
  • Phone: 757-473-0055
  • Fax:
Mailing address:
  • Phone: 757-963-0760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024167075
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: