Provider Demographics
NPI:1467422469
Name:GRATIAS, CONNIE M (FNP)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:M
Last Name:GRATIAS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 30TH AVE W
Mailing Address - Street 2:ALEXANDRIA CLINIC
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308
Mailing Address - Country:US
Mailing Address - Phone:320-763-5123
Mailing Address - Fax:320-763-7883
Practice Address - Street 1:610 30TH AVE W
Practice Address - Street 2:ALEXANDRIA CLINIC
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308
Practice Address - Country:US
Practice Address - Phone:320-763-5123
Practice Address - Fax:320-763-7883
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR0721761363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN500001667OtherRR MEDICARE
MN408724100Medicaid
MN500007647Medicare PIN
S35143Medicare UPIN
MN408724100Medicaid