Provider Demographics
NPI:1376142844
Name:WANDERSLEBEN, GRACE E (MD)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:E
Last Name:WANDERSLEBEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 155
Mailing Address - Street 2:
Mailing Address - City:RIO GRANDE
Mailing Address - State:PR
Mailing Address - Zip Code:00745-0155
Mailing Address - Country:US
Mailing Address - Phone:787-240-6585
Mailing Address - Fax:
Practice Address - Street 1:CARRETERA 188 KM 1.5 BARRIO SAN ISIDRO
Practice Address - Street 2:
Practice Address - City:CANOVANAS
Practice Address - State:PR
Practice Address - Zip Code:00729-3998
Practice Address - Country:US
Practice Address - Phone:787-957-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-25
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR022070208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice