Provider Demographics
NPI:1356866743
Name:SEBASTIAN, GRACY
Entity Type:Individual
Prefix:MRS
First Name:GRACY
Middle Name:
Last Name:SEBASTIAN
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 1:30 CREST DR
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10607-2718
Mailing Address - Country:US
Mailing Address - Phone:609-540-2483
Mailing Address - Fax:
Practice Address - Street 1:30 CREST DR
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10607-2718
Practice Address - Country:US
Practice Address - Phone:609-540-2483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-07
Last Update Date:2017-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF341159-1363LF0000X
NY9520088363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily