Provider Demographics
NPI:1801627286
Name:TAKISH, GRACE LUISE (FNP)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:LUISE
Last Name:TAKISH
Suffix:
Gender:
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 44897
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48244-0897
Mailing Address - Country:US
Mailing Address - Phone:734-604-1873
Mailing Address - Fax:
Practice Address - Street 1:11012 E 13 MILE RD STE 112
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-2546
Practice Address - Country:US
Practice Address - Phone:586-573-6880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-08
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704318984363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI381958736Medicaid
0E06376OtherBCBSM