Provider Demographics
NPI:1659306447
Name:CHERRY, GRACE (NP)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:CHERRY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD
Mailing Address - Street 2:STE 200
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:310-794-1092
Mailing Address - Fax:
Practice Address - Street 1:200 MEDICAL PLZ
Practice Address - Street 2:#365,214,420,120,510
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-3075
Practice Address - Country:US
Practice Address - Phone:310-794-1092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15069207RH0003X, 363L00000X
CA424933163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANP150690Medicaid
CAWNP15069AMedicare PIN
CANP150690Medicaid