Provider Demographics
NPI:1871676353
Name:MROZ, GRACE (NPP)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:MROZ
Suffix:
Gender:F
Credentials:NPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 WAVERLY AVE
Mailing Address - Street 2:BUILDING 4 SUITE 11
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-1555
Mailing Address - Country:US
Mailing Address - Phone:631-730-7503
Mailing Address - Fax:631-307-9422
Practice Address - Street 1:450 WAVERLY AVE
Practice Address - Street 2:BUILDING 4 SUITE 11
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-1555
Practice Address - Country:US
Practice Address - Phone:631-730-7503
Practice Address - Fax:631-307-9422
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY400668363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00659412Medicaid
NY00659412Medicaid