Provider Demographics
NPI:1164748281
Name:GRACE, TERESSA L (N/A)
Entity Type:Individual
Prefix:
First Name:TERESSA
Middle Name:L
Last Name:GRACE
Suffix:
Gender:F
Credentials:N/A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1742 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-6620
Mailing Address - Country:US
Mailing Address - Phone:662-621-9850
Mailing Address - Fax:662-621-9849
Practice Address - Street 1:1742 N STATE ST
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-6620
Practice Address - Country:US
Practice Address - Phone:662-621-9850
Practice Address - Fax:662-621-9849
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-14
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSA0337768376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07078593Medicaid
MS07078593Medicaid