MEDICARE: AMAZING GRACE PRIMARY CARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner

General Provider Information

NPI Number	:	1538827845
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMAZING GRACE PRIMARY CARE LLC

Provider Business Mailing Address
First Line	:	1412 CRAIN HWY N STE 3A
Second Line	:
City	:	GLEN BURNIE
State	:	MD
Zip	:	21061-7000
Country	:	US
Telephone Number	:	301-875-5511
Fax Number	:

Provider Business Practice Location Address
First Line	:	1412 CRAIN HWY N STE 3A
Second Line	:
City	:	GLEN BURNIE
State	:	MD
Zip	:	21061-7000
Country	:	US
Telephone Number	:	301-875-5511
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	GRACE OKHUEREIGBE
Credential	:	FNP
Telephone Number	:	301-875-5511

Provider Enumeration Date	:	12/03/2021
Last Update Date	:	12/03/2021

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