Provider Demographics
NPI:1093058976
Name:KOO, GRACE KIM (FNP-C)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:KIM
Last Name:KOO
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 W MAPLE ST
Mailing Address - Street 2:STE 306
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-2420
Mailing Address - Country:US
Mailing Address - Phone:678-455-9882
Mailing Address - Fax:678-455-9885
Practice Address - Street 1:514 W MAPLE ST STE 306
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-2420
Practice Address - Country:US
Practice Address - Phone:678-455-9885
Practice Address - Fax:678-455-9885
Is Sole Proprietor?:No
Enumeration Date:2013-03-29
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024171736363LF0000X
TN18490363LF0000X
GARN218400363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVVE648BMedicare PIN
TN103I509061Medicare PIN