Provider Demographics
NPI:1376950519
Name:ZANOLLI, GRACE (PA-C)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:ZANOLLI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 ELDEN AVE UNIT F
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-7435
Mailing Address - Country:US
Mailing Address - Phone:847-924-9222
Mailing Address - Fax:
Practice Address - Street 1:22431 ANTONIO PKWY # B160-613
Practice Address - Street 2:
Practice Address - City:RANCHO SANTA MARGARITA
Practice Address - State:CA
Practice Address - Zip Code:92688-2804
Practice Address - Country:US
Practice Address - Phone:855-727-2251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-21
Last Update Date:2023-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61194363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant