Provider Demographics
NPI:1013407139
Name:DENEUS, GRACELYN AMBRISTER (FNP)
Entity Type:Individual
Prefix:MRS
First Name:GRACELYN
Middle Name:AMBRISTER
Last Name:DENEUS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5009 TIWANAKU DR SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-7999
Mailing Address - Country:US
Mailing Address - Phone:404-349-0844
Mailing Address - Fax:
Practice Address - Street 1:3755 SIXES RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-7842
Practice Address - Country:US
Practice Address - Phone:404-395-0890
Practice Address - Fax:470-299-9936
Is Sole Proprietor?:No
Enumeration Date:2018-05-14
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN128736363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA049164407OtherDRIVERS LICENSE