Provider Demographics
NPI:1679246045
Name:GORMAN, GRACE PONGNEA
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:PONGNEA
Last Name:GORMAN
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 1:1093 E COUNTY ROAD 5718
Mailing Address - Street 2:
Mailing Address - City:NATALIA
Mailing Address - State:TX
Mailing Address - Zip Code:78059-2712
Mailing Address - Country:US
Mailing Address - Phone:210-326-9956
Mailing Address - Fax:
Practice Address - Street 1:1608 ROCK HOLLOW LOOP
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77807-2360
Practice Address - Country:US
Practice Address - Phone:210-326-9956
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-30
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program