Provider Demographics
NPI:1720362429
Name:GRACE PEDIATRICS PL
Entity Type:Organization
Organization Name:GRACE PEDIATRICS PL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/ARNP/CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-243-8474
Mailing Address - Street 1:4196 W US HIGHWAY 90
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-8834
Mailing Address - Country:US
Mailing Address - Phone:386-243-8474
Mailing Address - Fax:386-438-5945
Practice Address - Street 1:4196 W US HIGHWAY 90
Practice Address - Street 2:SUITE 105
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-8834
Practice Address - Country:US
Practice Address - Phone:386-243-8474
Practice Address - Fax:386-438-5945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-29
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9220069363LP0200X
FL2667852363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004797600Medicaid
FL68-3810OtherMEDICARE RHC CERTIFICATION