Provider Demographics
NPI:1023177458
Name:MOOREFIELD, GRACE ELIZABETH (MSN, ARN, BC)
Entity type:Individual
Prefix:MRS
First Name:GRACE
Middle Name:ELIZABETH
Last Name:MOOREFIELD
Suffix:
Gender:F
Credentials:MSN, ARN, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1494
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-1494
Mailing Address - Country:US
Mailing Address - Phone:626-253-2818
Mailing Address - Fax:626-606-0234
Practice Address - Street 1:701 EAST FOOTHILL BOULEVARD
Practice Address - Street 2:
Practice Address - City:AZUSA
Practice Address - State:CA
Practice Address - Zip Code:91702-7000
Practice Address - Country:US
Practice Address - Phone:626-253-2818
Practice Address - Fax:626-606-0234
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN257013101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS87567Medicare UPIN