Provider Demographics
NPI:1508305566
Name:ESTRADA, GRACELYN (LMT)
Entity Type:Individual
Prefix:
First Name:GRACELYN
Middle Name:
Last Name:ESTRADA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 S 225 E
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-4169
Mailing Address - Country:US
Mailing Address - Phone:385-239-2472
Mailing Address - Fax:
Practice Address - Street 1:955 S 225 E
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-4169
Practice Address - Country:US
Practice Address - Phone:385-239-2472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-22
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10149438-4701173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine