Provider Demographics
NPI:1710443114
Name:NESBITT, GRADY CLEMENCE (LAC)
Entity Type:Individual
Prefix:
First Name:GRADY
Middle Name:CLEMENCE
Last Name:NESBITT
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 NE TILLAMOOK ST APT 3
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-4062
Mailing Address - Country:US
Mailing Address - Phone:720-273-4254
Mailing Address - Fax:
Practice Address - Street 1:3537 N WILLIAMS AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1437
Practice Address - Country:US
Practice Address - Phone:720-273-4254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR185138171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist