Provider Demographics
NPI:1841741196
Name:GRACE INTERNAL MEDICINE, LLC
Entity Type:Organization
Organization Name:GRACE INTERNAL MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:WHITNEY
Authorized Official - Middle Name:DIANA
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:423-282-2700
Mailing Address - Street 1:2514 WESLEY ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-1764
Mailing Address - Country:US
Mailing Address - Phone:423-282-2700
Mailing Address - Fax:423-282-2802
Practice Address - Street 1:2514 WESLEY ST
Practice Address - Street 2:SUITE 102
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-1764
Practice Address - Country:US
Practice Address - Phone:423-282-2700
Practice Address - Fax:423-282-2802
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRACE INTERNAL MEDICINE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2497363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty