Provider Demographics
NPI:1558875054
Name:GRACE, BEVERLY LYNETTE
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:LYNETTE
Last Name:GRACE
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 1:3525 RESOURCE DR
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-4733
Mailing Address - Country:US
Mailing Address - Phone:410-887-0607
Mailing Address - Fax:
Practice Address - Street 1:3525 RESOURCE DR
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-4733
Practice Address - Country:US
Practice Address - Phone:410-887-0607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-21
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR113035163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR113035OtherR/N.