Provider Demographics
NPI:1114699113
Name:GRACE, SHAWANDA
Entity Type:Individual
Prefix:
First Name:SHAWANDA
Middle Name:
Last Name:GRACE
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 1:333 WASHINGTON AVE APT 104
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-5153
Mailing Address - Country:US
Mailing Address - Phone:216-213-9395
Mailing Address - Fax:
Practice Address - Street 1:333 WASHINGTON AVE APT 104
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-5153
Practice Address - Country:US
Practice Address - Phone:216-213-9395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-29
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker