Provider Demographics
NPI:1679699284
Name:GRACE, SUSAN (APRN)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:GRACE
Suffix:
Gender:F
Credentials:APRN
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 725
Mailing Address - Street 2:
Mailing Address - City:COVENTRY
Mailing Address - State:CT
Mailing Address - Zip Code:06238-0725
Mailing Address - Country:US
Mailing Address - Phone:860-989-0035
Mailing Address - Fax:
Practice Address - Street 1:1153 MAIN ST
Practice Address - Street 2:
Practice Address - City:COVENTRY
Practice Address - State:CT
Practice Address - Zip Code:06238-3115
Practice Address - Country:US
Practice Address - Phone:860-341-2776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2018-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002645363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT002645OtherAPRN