Provider Demographics
NPI:1326749391
Name:CARPENTER, GRACE LAUREN
Entity Type:Individual
Prefix:MISS
First Name:GRACE
Middle Name:LAUREN
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4028 HARRISON CREEK CT
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-9159
Mailing Address - Country:US
Mailing Address - Phone:574-850-6441
Mailing Address - Fax:
Practice Address - Street 1:5215 HOLY CROSS PKWY
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1469
Practice Address - Country:US
Practice Address - Phone:574-850-6441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-15
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN45021866A390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program