Provider Demographics
NPI:1235864133
Name:BERTOLI, GRACE CATHERINE
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:CATHERINE
Last Name:BERTOLI
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 1:544 STONETRACE DR
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37128-7604
Mailing Address - Country:US
Mailing Address - Phone:615-663-3394
Mailing Address - Fax:
Practice Address - Street 1:167 ASHLEY AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-2834
Practice Address - Country:US
Practice Address - Phone:615-663-3394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-24
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SC5018363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program