Provider Demographics
NPI:1891838629
Name:GRACE, SUSAN K (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:K
Last Name:GRACE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 TEEGARDEN ST
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-3175
Mailing Address - Country:US
Mailing Address - Phone:219-326-0043
Mailing Address - Fax:219-326-8909
Practice Address - Street 1:400 TEEGARDEN ST
Practice Address - Street 2:SUITE B
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-3175
Practice Address - Country:US
Practice Address - Phone:219-326-0043
Practice Address - Fax:219-326-8909
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000443363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200812400Medicaid