Provider Demographics
NPI:1982487542
Name:WEDDLE, GRACE NICOLE (DPT)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:NICOLE
Last Name:WEDDLE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 FAIRGROUNDS RD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-5443
Mailing Address - Country:US
Mailing Address - Phone:573-634-3070
Mailing Address - Fax:
Practice Address - Street 1:1115 FAIRGROUNDS RD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-5443
Practice Address - Country:US
Practice Address - Phone:573-634-3070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023032246225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist