Provider Demographics
NPI:1174839526
Name:GRACE, CHARLENE (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLENE
Middle Name:
Last Name:GRACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:CHARLENE
Other - Middle Name:
Other - Last Name:GRACE FOSTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:954 WOODFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WEST HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11552-4151
Mailing Address - Country:US
Mailing Address - Phone:516-678-0921
Mailing Address - Fax:
Practice Address - Street 1:55 MAPLE AVE STE 102
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-4267
Practice Address - Country:US
Practice Address - Phone:516-536-2221
Practice Address - Fax:516-764-8747
Is Sole Proprietor?:No
Enumeration Date:2010-08-24
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY317303207Q00000X
MO2010028268390200000X
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program