Provider Demographics
NPI:1932708617
Name:GRACE FAMILY PRACTICE
Entity Type:Organization
Organization Name:GRACE FAMILY PRACTICE
Other - Org Name:GRACELAND FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:FICKLING
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, FNP-C
Authorized Official - Phone:850-741-2878
Mailing Address - Street 1:6470 TIPPIN AVE
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-8143
Mailing Address - Country:US
Mailing Address - Phone:850-741-2878
Mailing Address - Fax:
Practice Address - Street 1:6470 TIPPIN AVE
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8143
Practice Address - Country:US
Practice Address - Phone:850-741-2878
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-22
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1184196669Medicaid