Organization Name: | GRACEVILLE FAMILY MEDICINE INC |
NPI Number: | 1154691566 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | LUCINDA W COLLINS (OWNER) |
Mailing Address: | 5239 Brown St Graceville |
State: | FL US |
Postal Code: | 324402513 |
Phone Number: | 8503604909 |
Fax Number: | 8503604911 |
NPI Enumeration Date: | 01/03/2012 |
NPI Last Update Date: | 09/16/2014 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 363LF0000X |
License Number: | 9321958 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | FL |
Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
Taxonomy Classification: | Nurse Practitioner |
Taxonomy Specialization: | Family |
Taxonomy Definition: |