Provider Demographics
NPI:1356843940
Name:GRADY, NICOLE (PA, ATC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:GRADY
Suffix:
Gender:
Credentials:PA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 BARRA RD STE 103
Mailing Address - Street 2:
Mailing Address - City:BIDDEFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04005-9461
Mailing Address - Country:US
Mailing Address - Phone:207-283-1126
Mailing Address - Fax:207-294-3544
Practice Address - Street 1:46 BARRA RD STE 103
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-9461
Practice Address - Country:US
Practice Address - Phone:207-283-1126
Practice Address - Fax:207-294-3544
Is Sole Proprietor?:No
Enumeration Date:2018-02-28
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAT8052255A2300X
MEPA2817363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant