Provider Demographics
NPI:1568232148
Name:ANTHONY, GRACE KATHERINE (PTA)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:KATHERINE
Last Name:ANTHONY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 CONESTOGA DR SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87123-4269
Mailing Address - Country:US
Mailing Address - Phone:216-612-4145
Mailing Address - Fax:
Practice Address - Street 1:5006 COPPER AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-1301
Practice Address - Country:US
Practice Address - Phone:505-268-7988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-04
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPTA22010225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant