Provider Demographics
NPI:1831926492
Name:DOUGLAS, GRACE KATHERINE
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:KATHERINE
Last Name:DOUGLAS
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 1:321 WASHINGTON ST APT 1
Mailing Address - Street 2:
Mailing Address - City:WINONA
Mailing Address - State:MN
Mailing Address - Zip Code:55987-2942
Mailing Address - Country:US
Mailing Address - Phone:507-251-7645
Mailing Address - Fax:
Practice Address - Street 1:321 WASHINGTON ST APT 1
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987-2942
Practice Address - Country:US
Practice Address - Phone:507-251-7645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-17
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer