Provider Demographics
NPI:1649288010
Name:GRACE, CARROLLYN E (APRN PCNS)
Entity type:Individual
Prefix:
First Name:CARROLLYN
Middle Name:E
Last Name:GRACE
Suffix:
Gender:F
Credentials:APRN PCNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 BLACKSTONE BLVD
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906
Mailing Address - Country:US
Mailing Address - Phone:401-270-7757
Mailing Address - Fax:401-270-5788
Practice Address - Street 1:345 BLACKSTONE BLVD
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906
Practice Address - Country:US
Practice Address - Phone:401-270-7757
Practice Address - Fax:401-270-5788
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPPNS00044364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI899023617899023617Medicare ID - Type Unspecified