Provider Demographics
NPI:1003876814
Name:GRADY, STEPHANIE (PA & NP)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:
Last Name:GRADY
Suffix:
Gender:F
Credentials:PA & NP
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:G
Other - Last Name:RODRIQUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA & NP
Mailing Address - Street 1:PO BOX 43
Mailing Address - Street 2:MR 10809
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440-0043
Mailing Address - Country:US
Mailing Address - Phone:612-262-4813
Mailing Address - Fax:612-262-4194
Practice Address - Street 1:410 CHURCH ST SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0222
Practice Address - Country:US
Practice Address - Phone:612-625-2612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9028207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN326725300Medicaid
MN326725300Medicaid
R14494Medicare UPIN