Provider Demographics
NPI:1821262064
Name:MALE, GRACE
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:MALE
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 1:2801 W KINNICKINNIC RIVER PKWY
Mailing Address - Street 2:POB SUITE 175
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-3669
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2801 W KINNICKINNIC RIVER PKWY
Practice Address - Street 2:POB SUITE 175
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-3669
Practice Address - Country:US
Practice Address - Phone:414-649-7909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-18
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program