Provider Demographics
NPI:1710461595
Name:FANTL, GRACE (PA-C)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:FANTL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 FAUNCE CORNER MALL RD
Mailing Address - Street 2:
Mailing Address - City:N DARTMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02747-6216
Mailing Address - Country:US
Mailing Address - Phone:508-993-7601
Mailing Address - Fax:508-997-0523
Practice Address - Street 1:145 FAUNCE CORNER MALL RD
Practice Address - Street 2:
Practice Address - City:N DARTMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02747-6216
Practice Address - Country:US
Practice Address - Phone:508-993-7601
Practice Address - Fax:508-997-0523
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA8620363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant