Provider Demographics
NPI:1275756868
Name:FORSYTHE, GRACE A (PHD, APRN)
Entity Type:Individual
Prefix:DR
First Name:GRACE
Middle Name:A
Last Name:FORSYTHE
Suffix:
Gender:F
Credentials:PHD, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4271 NEPTUNE DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-3362
Mailing Address - Country:US
Mailing Address - Phone:801-273-7769
Mailing Address - Fax:801-273-4073
Practice Address - Street 1:2046 MURRAY HOLLADAY RD
Practice Address - Street 2:103
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-5125
Practice Address - Country:US
Practice Address - Phone:801-273-7769
Practice Address - Fax:801-273-4073
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2189134405363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT267698Medicare UPIN