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General NPI Number Information
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NPI Number | 1467017491
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Entity Type | Organization
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Legal Business Name | GRACE FAMILY HEALTHCARE
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Dates
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Enumeration Date | 05/06/2019
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Last Update Date | 05/06/2019
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Provider Practice Location Address
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Address Line | 102 LAKESHORE DR STE B
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City | SAINT MARYS
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State | GA
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Zip | 31558-3875
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Country | US
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Telephone | 912-729-2955
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Fax | 912-882-4897
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Provider Business Mailing Address
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Address Line | 102 LAKESHORE DR STE B
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City | SAINT MARYS
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State | GA
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Zip | 31558-3875
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Country | US
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Telephone |
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Fax | 912-882-4897
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Authorized Official
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Title or Position | NURSE PRACTITIONER
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Name | ANGELA DAWN JOHNSON
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Credential | ARNP
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Telephone | 912-729-2955
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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