Healthcare Provider Details

I. General information

NPI: 1790318186
Provider Name (Legal Business Name): GRACE EDITH LINE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2020
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4125 E ITASCA ST
SUPERIOR WI
54880-4239
US

IV. Provider business mailing address

4125 E ITASCA ST
SUPERIOR WI
54880-4239
US

V. Phone/Fax

Practice location:
  • Phone: 218-481-5357
  • Fax:
Mailing address:
  • Phone: 218-481-5357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberL500-3056-2668-05
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: