Provider Demographics
NPI:1073296224
Name:COUCH, GRACE (FNP)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:COUCH
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 1:24079 67TH AVE
Mailing Address - Street 2:
Mailing Address - City:DOUGLASTON
Mailing Address - State:NY
Mailing Address - Zip Code:11362-1926
Mailing Address - Country:US
Mailing Address - Phone:718-869-4356
Mailing Address - Fax:
Practice Address - Street 1:865 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5335
Practice Address - Country:US
Practice Address - Phone:516-622-5114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF352163-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily