Provider Demographics
NPI:1710591946
Name:SIMON, GRACIE RAE (NP)
Entity Type:Individual
Prefix:
First Name:GRACIE
Middle Name:RAE
Last Name:SIMON
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 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8617
Mailing Address - Fax:
Practice Address - Street 1:298 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29672-9443
Practice Address - Country:US
Practice Address - Phone:864-885-7758
Practice Address - Fax:864-885-7749
Is Sole Proprietor?:No
Enumeration Date:2020-09-04
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC24288363LF0000X
SC227277163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse