Provider Demographics
NPI:1568437135
Name:GRACE, SALLY L (APN)
Entity Type:Individual
Prefix:MS
First Name:SALLY
Middle Name:L
Last Name:GRACE
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 E EMMA AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-4634
Mailing Address - Country:US
Mailing Address - Phone:479-751-7417
Mailing Address - Fax:479-751-4898
Practice Address - Street 1:614 E EMMA AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-4634
Practice Address - Country:US
Practice Address - Phone:479-751-7417
Practice Address - Fax:479-751-4898
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA01038363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR190222758Medicaid
ARA01038OtherSTATE LICENSE
ARS72855Medicare UPIN
ARA01038OtherSTATE LICENSE