Provider Demographics
NPI:1396304671
Name:PEELER STANKIEWICZ, GRACE
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:PEELER STANKIEWICZ
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 1:148 CLARA AVE
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-4002
Mailing Address - Country:US
Mailing Address - Phone:707-462-1932
Mailing Address - Fax:
Practice Address - Street 1:148 CLARA AVE
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-4002
Practice Address - Country:US
Practice Address - Phone:707-462-1932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
NA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA680159027OtherMEDICAL
CA68-0159027OtherMEDI-CAL