Provider Demographics
NPI:1407299324
Name:WARD, GRACE LUCTA (MD)
Entity Type:Individual
Prefix:DR
First Name:GRACE
Middle Name:LUCTA
Last Name:WARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:LUCTA
Other - Last Name:GERALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:105 W STONE DR STE 4A
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3365
Mailing Address - Country:US
Mailing Address - Phone:423-392-6265
Mailing Address - Fax:423-392-6272
Practice Address - Street 1:105 W STONE DR
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660
Practice Address - Country:US
Practice Address - Phone:423-392-6265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-10
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN57975208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty