Provider Demographics
NPI:1033472063
Name:FITZGERALD, GRACE
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 DESANCTIS DR
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND MILLS
Mailing Address - State:NY
Mailing Address - Zip Code:10930-3420
Mailing Address - Country:US
Mailing Address - Phone:845-928-7873
Mailing Address - Fax:
Practice Address - Street 1:66 WASHINGTON DR
Practice Address - Street 2:
Practice Address - City:HIGHLAND MILLS
Practice Address - State:NY
Practice Address - Zip Code:10930-3030
Practice Address - Country:US
Practice Address - Phone:845-928-2579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-25
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist