Provider Demographics
NPI:1689097412
Name:GRADY, KATIE LEIGH (NP)
Entity Type:Individual
Prefix:
First Name:KATIE LEIGH
Middle Name:
Last Name:GRADY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1559
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-0989
Mailing Address - Country:US
Mailing Address - Phone:631-444-0650
Mailing Address - Fax:631-638-4170
Practice Address - Street 1:179 N BELLE MEAD RD
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-3528
Practice Address - Country:US
Practice Address - Phone:631-444-2599
Practice Address - Fax:631-444-1474
Is Sole Proprietor?:No
Enumeration Date:2014-01-30
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY306512363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner