Provider Demographics
NPI:1073948923
Name:GRACE, AMY KATHERYN (FNP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:KATHERYN
Last Name:GRACE
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:PO BOX 491
Mailing Address - Street 2:
Mailing Address - City:CANNON BEACH
Mailing Address - State:OR
Mailing Address - Zip Code:97110-0491
Mailing Address - Country:US
Mailing Address - Phone:307-760-4262
Mailing Address - Fax:
Practice Address - Street 1:2111 EXCHANGE ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-3329
Practice Address - Country:US
Practice Address - Phone:503-325-4321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-11
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201505838363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily