Healthcare Provider Details

I. General information

NPI: 1124227244
Provider Name (Legal Business Name): GRACEANN A FREEMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2007
Last Update Date: 07/31/2025
Certification Date: 07/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 W 1ST ST
WAPATO WA
98951-1108
US

IV. Provider business mailing address

PO BOX 15645
LAS VEGAS NV
89114-5645
US

V. Phone/Fax

Practice location:
  • Phone: 509-887-4111
  • Fax:
Mailing address:
  • Phone: 702-579-3298
  • Fax: 702-667-4689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP61599120
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN000955
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: