Provider Demographics
NPI:1982767786
Name:GRAJALES, GRACE K (FNP)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:K
Last Name:GRAJALES
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 FLANDERS RD
Mailing Address - Street 2:
Mailing Address - City:EAST LYME
Mailing Address - State:CT
Mailing Address - Zip Code:06333-1743
Mailing Address - Country:US
Mailing Address - Phone:860-739-0348
Mailing Address - Fax:860-739-6779
Practice Address - Street 1:305 FLANDERS RD
Practice Address - Street 2:
Practice Address - City:EAST LYME
Practice Address - State:CT
Practice Address - Zip Code:06333-1743
Practice Address - Country:US
Practice Address - Phone:860-739-0348
Practice Address - Fax:860-739-6779
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4274363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008039710Medicaid
CT008072609Medicaid
S86492Medicare UPIN