Provider Demographics
NPI:1417625336
Name:WALCOTT, GRACE ANNA
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:ANNA
Last Name:WALCOTT
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 1:5775 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94618-1571
Mailing Address - Country:US
Mailing Address - Phone:510-459-0346
Mailing Address - Fax:
Practice Address - Street 1:2712 TELEGRAPH AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-1117
Practice Address - Country:US
Practice Address - Phone:510-548-8283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-03
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program