Provider Demographics
NPI:1821702663
Name:AMAZING GRACE PRIMARY CARE, LLC
Entity Type:Organization
Organization Name:AMAZING GRACE PRIMARY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP, DNP, FNP-BC
Authorized Official - Phone:352-949-0478
Mailing Address - Street 1:1350 NW US HIGHWAY 27
Mailing Address - Street 2:
Mailing Address - City:CHIEFLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32626-3541
Mailing Address - Country:US
Mailing Address - Phone:352-949-0478
Mailing Address - Fax:352-754-3305
Practice Address - Street 1:410 N MAIN ST STE 11
Practice Address - Street 2:
Practice Address - City:CHIEFLAND
Practice Address - State:FL
Practice Address - Zip Code:32626-0866
Practice Address - Country:US
Practice Address - Phone:352-949-0478
Practice Address - Fax:352-752-3305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-06
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Multi-Specialty