MEDICARE: GRACE PEDIATRICS PL

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	363LP0200X	Pediatric Nurse Practitioner	9220069	FL
2	363LP0200X	Pediatric Nurse Practitioner	2667852	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	68-3810	OTHER	FL	MEDICARE RHC CERTIFICATION

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720362429
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACE PEDIATRICS PL

Provider Business Mailing Address
First Line	:	4196 W US HIGHWAY 90
Second Line	:	SUITE 105
City	:	LAKE CITY
State	:	FL
Zip	:	32055-8834
Country	:	US
Telephone Number	:	386-243-8474
Fax Number	:	386-438-5945

Provider Business Practice Location Address
First Line	:	4196 W US HIGHWAY 90
Second Line	:	SUITE 105
City	:	LAKE CITY
State	:	FL
Zip	:	32055-8834
Country	:	US
Telephone Number	:	386-243-8474
Fax Number	:	386-438-5945

Authorized Official
Title or Position	:	MANAGER/ARNP/CO-OWNER
Name	:	COLLEEN THOMPSON
Credential	:
Telephone Number	:	386-243-8474

Provider Enumeration Date	:	09/29/2011
Last Update Date	:	02/19/2014

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Directions to “GRACE PEDIATRICS PL ” Practice Location

Language	Start Address	Practice Location

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