Provider Demographics
NPI:1376181339
Name:ERICKSON, GRACE
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:ERICKSON
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 1:1325 STATE ST
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-4071
Mailing Address - Country:US
Mailing Address - Phone:612-222-8071
Mailing Address - Fax:
Practice Address - Street 1:1325 STATE ST
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-4071
Practice Address - Country:US
Practice Address - Phone:612-222-8071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-20
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN38447870OtherHEALTH PARTNERS