Provider Demographics
NPI:1255442810
Name:STANLEY, GRACE L (NP)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:L
Last Name:STANLEY
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8 JOHN KISSINGER DR
Practice Address - Street 2:
Practice Address - City:WABASH
Practice Address - State:IN
Practice Address - Zip Code:46992-1648
Practice Address - Country:US
Practice Address - Phone:260-563-7451
Practice Address - Fax:260-569-2284
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000568A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200081850AMedicaid
INP10428Medicare UPIN
IN113150FFFFMedicare ID - Type Unspecified