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General NPI Number Information
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NPI Number | 1720362429
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Entity Type | Organization
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Legal Business Name | GRACE PEDIATRICS PL
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Dates
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Enumeration Date | 09/29/2011
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Last Update Date | 02/19/2014
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Provider Practice Location Address
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Address Line | 4196 W US HIGHWAY 90 SUITE 105
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City | LAKE CITY
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State | FL
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Zip | 32055-8834
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Country | US
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Telephone | 386-243-8474
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Fax | 386-438-5945
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Provider Business Mailing Address
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Address Line | 4196 W US HIGHWAY 90 SUITE 105
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City | LAKE CITY
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State | FL
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Zip | 32055-8834
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Country | US
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Telephone | 386-243-8474
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Fax | 386-438-5945
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Authorized Official
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Title or Position | MANAGER/ARNP/CO-OWNER
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Name | COLLEEN THOMPSON
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Credential |
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Telephone | 386-243-8474
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0200X
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Taxonomy Name | Pediatric Nurse Practitioner
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License Number | 9220069
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 363LP0200X
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Taxonomy Name | Pediatric Nurse Practitioner
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License Number | 2667852
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License Number State | FL
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