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General NPI Number Information
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NPI Number | 1104146133
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Entity Type | Individual
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Provider Name | JOLIETTE NICOLE GRACE M.D.
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Gender | Female
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Dates
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Enumeration Date | 06/01/2010
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Last Update Date | 10/22/2024
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Provider Practice Location Address
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Address Line | 200 HERLONG AVE S STE G
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City | ROCK HILL
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State | SC
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Zip | 29732-1182
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Country | US
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Telephone | 803-909-6300
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Fax | 803-909-6310
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Provider Business Mailing Address
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Address Line | 13111 BRIDGEPORT XING
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City | BRADENTON
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State | FL
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Zip | 34211-4002
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Country | US
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Telephone | 573-703-5663
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 93469
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License Number State | SC
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Taxonomy #2
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | ME133013
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 2086S0127X
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Taxonomy Name | Trauma Surgery Physician
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License Number | ME133013
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License Number State | FL
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