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NPI Code Detail

MEDICARE: GRACE MBA

MEDICARE: GRACE MBA
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
1363LP0808XPsychiatric/Mental Health Nurse PractitionerNP500020241DC
2363LP0808XPsychiatric/Mental Health Nurse PractitionerAC006732MD

General Provider Information

NPI Number : 1720810492
Entity Type Code : Individual
Provider Name (Legal Business Name) : GRACE MBA
Provider Business Mailing Address
First Line : 6012 BLACK BEAR CT
Second Line :
City : WALDORF
State : MD
Zip : 20603-4342
Country : US
Telephone Number : 240-413-4491
Fax Number :
Provider Business Practice Location Address
First Line : 3261 OLD WASHINGTON RD STE 2020
Second Line :
City : WALDORF
State : MD
Zip : 20602-3231
Country : US
Telephone Number : 301-710-4218
Fax Number : 301-396-7346
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/20/2024
Last Update Date : 01/16/2026

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Directions to “ GRACE MBA ” Practice Location

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