Provider Demographics
NPI:1194366757
Name:CLONCH, GRACE CATHERINE
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:CATHERINE
Last Name:CLONCH
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 1:3450 MONONGAHELA BLVD
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-3043
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3450 MONOGAHELA BLVD
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505
Practice Address - Country:US
Practice Address - Phone:304-293-9868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-04
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program