Provider Demographics
NPI:1245088632
Name:GRACE, PEYTON
Entity type:Individual
Prefix:
First Name:PEYTON
Middle Name:
Last Name:GRACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73143 MEADOW LARK DR
Mailing Address - Street 2:
Mailing Address - City:ABITA SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70420-2533
Mailing Address - Country:US
Mailing Address - Phone:985-773-0504
Mailing Address - Fax:
Practice Address - Street 1:500 W UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70401-1304
Practice Address - Country:US
Practice Address - Phone:985-773-0504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-09
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program