Provider Demographics
NPI:1750901229
Name:BERNAUDO, GRACE
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:BERNAUDO
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 1:151 INGRAHAM LN
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-4275
Mailing Address - Country:US
Mailing Address - Phone:516-437-0796
Mailing Address - Fax:
Practice Address - Street 1:101 MINEOLA BLVD
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-4089
Practice Address - Country:US
Practice Address - Phone:516-663-3511
Practice Address - Fax:516-663-2308
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-24
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY516568207RE0101X
NY309694363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism