=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871786673
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRACE WOMENS CLINIC PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2007
-----------------------------------------------------
Last Update Date | 04/24/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2280 S CHURCH ST STE 201 SUITE 201
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27215-5397
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-538-2014
-----------------------------------------------------
Fax | 336-538-2015
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2280 S CHURCH ST STE 201 SUITE 201
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27215-5397
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-538-2014
-----------------------------------------------------
Fax | 336-538-2015
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. LYNDE KNOWLES-JONAS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 336-538-2014
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 9800935
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------