Provider Demographics
NPI:1295185676
Name:PAGTAKHAN, GRACE (NP-C)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:PAGTAKHAN
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7400 DOCS GROVE CIR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-8010
Mailing Address - Country:US
Mailing Address - Phone:407-352-9717
Mailing Address - Fax:407-354-5425
Practice Address - Street 1:7400 DOCS GROVE CIR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819
Practice Address - Country:US
Practice Address - Phone:407-352-9717
Practice Address - Fax:407-354-5425
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024173648363LF0000X
FL9484394363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily