Provider Demographics
NPI:1942351937
Name:GRADELESS, MARIANNE (GONP)
Entity Type:Individual
Prefix:
First Name:MARIANNE
Middle Name:
Last Name:GRADELESS
Suffix:
Gender:F
Credentials:GONP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4810 S CROATAN HWY
Mailing Address - Street 2:SUITE 250
Mailing Address - City:NAGS HEAD
Mailing Address - State:NC
Mailing Address - Zip Code:27959-8508
Mailing Address - Country:US
Mailing Address - Phone:252-261-4885
Mailing Address - Fax:252-441-2641
Practice Address - Street 1:112 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-3361
Practice Address - Country:US
Practice Address - Phone:252-338-2151
Practice Address - Fax:252-338-2505
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC017944363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7949645Medicaid
NCS43547Medicare UPIN
NC2596101Medicare PIN