Provider Demographics
NPI:1477378164
Name:GRACE CARE MEDICAL LLC
Entity type:Organization
Organization Name:GRACE CARE MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:MOULTRIE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:850-712-5877
Mailing Address - Street 1:3631 GODWIN LN
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32526-8037
Mailing Address - Country:US
Mailing Address - Phone:850-960-7971
Mailing Address - Fax:
Practice Address - Street 1:4929 MOBILE HWY
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32506-3229
Practice Address - Country:US
Practice Address - Phone:850-960-7971
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-19
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty