Provider Demographics
NPI:1639543937
Name:ROXAS, GRACE MARIE
Entity Type:Individual
Prefix:
First Name:GRACE MARIE
Middle Name:
Last Name:ROXAS
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 1:2570 FOXFIELD RD STE 107
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-1406
Mailing Address - Country:US
Mailing Address - Phone:888-428-7890
Mailing Address - Fax:888-428-7891
Practice Address - Street 1:2025 SALEM ROAD
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-9006
Practice Address - Country:US
Practice Address - Phone:224-238-3441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-24
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277001341363LP0808X
IL209013581363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily