Provider Demographics
NPI:1932578671
Name:MAINA, GRACE W
Entity Type:Individual
Prefix:MS
First Name:GRACE
Middle Name:W
Last Name:MAINA
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 1:4545 FULLER DRIVE
Mailing Address - Street 2:STE 325
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-6521
Mailing Address - Country:US
Mailing Address - Phone:972-870-5511
Mailing Address - Fax:
Practice Address - Street 1:4545 FULLER DR STE 325
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-6530
Practice Address - Country:US
Practice Address - Phone:972-870-5511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-23
Last Update Date:2017-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP128840363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily