Provider Demographics
NPI:1376815134
Name:FORD, GRACE P (FNP-BC)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:P
Last Name:FORD
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:P
Other - Last Name:O'HARA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:305 W MOODY ST
Mailing Address - Street 2:
Mailing Address - City:POPLARVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39470-7338
Mailing Address - Country:US
Mailing Address - Phone:601-795-4543
Mailing Address - Fax:601-795-4238
Practice Address - Street 1:302 HIGHWAY 11 S
Practice Address - Street 2:
Practice Address - City:POPLARVILLE
Practice Address - State:MS
Practice Address - Zip Code:39470-2625
Practice Address - Country:US
Practice Address - Phone:601-403-8283
Practice Address - Fax:601-403-8283
Is Sole Proprietor?:No
Enumeration Date:2012-02-08
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS875721363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS12346339OtherCAQH
MS9858831OtherAETNA
MS07509343Medicaid
MS9858831OtherAETNA