Provider Demographics
NPI:1316005580
Name:PUTHENPURACKAL, GRACE (RD, LDN, CDE)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:PUTHENPURACKAL
Suffix:
Gender:F
Credentials:RD, LDN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3993 TRACE HOLLOW RUN
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-2552
Mailing Address - Country:US
Mailing Address - Phone:410-548-1860
Mailing Address - Fax:410-341-4629
Practice Address - Street 1:3993 TRACE HOLLOW RUN
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-2552
Practice Address - Country:US
Practice Address - Phone:410-548-1860
Practice Address - Fax:410-341-4629
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDO1175133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD6300008OtherUNITED HEALTH CARE
MD7758298OtherCIGNA
MDS2360001OtherBLUECHOICE,CAREFIRST
MDV00003940OtherAMERICHOICEMA
MD022022OtherPRIORITYPARTNERS.JHHC
MD0956915OtherAETNA HMO
MD328392OtherPRIMEHEALTH
MD228231300Medicaid
MD7758298OtherCIGNA,HMO,PPO
MD238074OtherAMERIHEALTH
MD09DIOtherCAREFIRSTBCBS,PPO,POS
MD216451OtherALLIANCE.MAMSI.MDIPA.OC
MD216451OtherAMERI HEALTH ADMINISTRATO
MD5640256OtherAETNA,PPO,POS
MD216451OtherAMERI HEALTH ADMINISTRATO