Provider Demographics
NPI:1518542034
Name:PACK, GRACE
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:PACK
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 884
Mailing Address - Street 2:
Mailing Address - City:SHADY SPRING
Mailing Address - State:WV
Mailing Address - Zip Code:25918-0884
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 ADKINS STREET
Practice Address - Street 2:
Practice Address - City:SHADY SPRING
Practice Address - State:WV
Practice Address - Zip Code:25918
Practice Address - Country:US
Practice Address - Phone:304-573-3345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-16
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker