Provider Demographics
NPI:1982991576
Name:GLEASON, GRACE (APN)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:GLEASON
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3299
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89702-3299
Mailing Address - Country:US
Mailing Address - Phone:775-222-0042
Mailing Address - Fax:
Practice Address - Street 1:3050 N ORMSBY BLVD
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89703-8378
Practice Address - Country:US
Practice Address - Phone:775-781-0092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-01
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV822282363LA2200X
IL209008861363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1982991576OtherTRICARE STANDARD
IL041346210OtherNURSE REGISTERED PROFESSIONAL
IL209008861OtherCERTIFIED NURSE PRACITIONER
IL041346210OtherNURSE REGISTERED PROFESSIONAL