Provider Demographics
NPI:1164974069
Name:JETAWO, GRACE (RN)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:JETAWO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 TWIN PINES DR
Mailing Address - Street 2:APT 13C
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11239-1810
Mailing Address - Country:US
Mailing Address - Phone:347-749-2492
Mailing Address - Fax:
Practice Address - Street 1:547 SAW MILL RIVER RD
Practice Address - Street 2:SUITE 3A
Practice Address - City:ARDSLEY
Practice Address - State:NY
Practice Address - Zip Code:10502-2143
Practice Address - Country:US
Practice Address - Phone:212-687-7464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-27
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY698471-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse