Provider Demographics
NPI:1295466217
Name:RELLICK, GRACE NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:NICOLE
Last Name:RELLICK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:559 MARGUERITE RD
Mailing Address - Street 2:
Mailing Address - City:LATROBE
Mailing Address - State:PA
Mailing Address - Zip Code:15650-5167
Mailing Address - Country:US
Mailing Address - Phone:724-691-4493
Mailing Address - Fax:
Practice Address - Street 1:532 W PITTSBURGH ST
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15601-2239
Practice Address - Country:US
Practice Address - Phone:724-689-1335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-21
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA063640363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical