Provider Demographics
NPI:1770557423
Name:GRACIA, CAROLYN M (APRN)
Entity type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:M
Last Name:GRACIA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 POPLAR AVE BLDG 2
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38105-4607
Mailing Address - Country:US
Mailing Address - Phone:901-287-7337
Mailing Address - Fax:
Practice Address - Street 1:51 N DUNLAP ST
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38105-4625
Practice Address - Country:US
Practice Address - Phone:901-287-7337
Practice Address - Fax:901-387-5151
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9206478163W00000X, 363L00000X
TN28797363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ064647Medicaid
FL018868100Medicaid