Provider Demographics
NPI:1326384371
Name:RESURRECCION, GRACE GONZALES (LPN)
Entity Type:Individual
Prefix:MISS
First Name:GRACE
Middle Name:GONZALES
Last Name:RESURRECCION
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3425 KINGSBRIDGE AVE
Mailing Address - Street 2:APT. 305
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-4016
Mailing Address - Country:US
Mailing Address - Phone:757-646-1649
Mailing Address - Fax:
Practice Address - Street 1:3425 KINGSBRIDGE AVE
Practice Address - Street 2:APT. 305
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-4016
Practice Address - Country:US
Practice Address - Phone:757-646-1649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-19
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY191715-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse