Provider Demographics
NPI:1912235276
Name:PHAN, GRACE GOTOS (LPT)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:GOTOS
Last Name:PHAN
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2812 BREAKER WAY
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95209-4265
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2812 BREAKER WAY
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95209-4265
Practice Address - Country:US
Practice Address - Phone:209-351-7132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-25
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT32760374700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician