Provider Demographics
NPI:1437730561
Name:PADILLA, GRACIE
Entity Type:Individual
Prefix:
First Name:GRACIE
Middle Name:
Last Name:PADILLA
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:PO BOX 848491
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-8491
Mailing Address - Country:US
Mailing Address - Phone:254-202-9330
Mailing Address - Fax:254-202-9349
Practice Address - Street 1:100 HILLCREST MEDICAL BLVD
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-8897
Practice Address - Country:US
Practice Address - Phone:252-202-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-20
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1033754363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care