Provider Demographics
NPI:1790318186
Name:LINE, GRACE EDITH
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:EDITH
Last Name:LINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15192
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55815-0192
Mailing Address - Country:US
Mailing Address - Phone:218-481-5357
Mailing Address - Fax:
Practice Address - Street 1:2934 168TH LN NW
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-1928
Practice Address - Country:US
Practice Address - Phone:218-481-5357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-13
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNB772-020-465-216172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver