# GRACE PEDIATRICS PL

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1720362429
- **Authorized official:** COLLEEN THOMPSON (MANAGER/ARNP/CO-OWNER)
- **Authorized official phone:** (386) 243-8474

## Contact information

- **Practice address:** 4196 W US HIGHWAY 90, SUITE 105, LAKE CITY, FL 32055-8834
- **Practice address phone:** (386) 243-8474
- **Practice address fax:** (386) 438-5945
- **Mailing address:** 4196 W US HIGHWAY 90, SUITE 105, LAKE CITY, FL 32055-8834
- **Mailing address phone:** (386) 243-8474
- **Mailing address fax:** (386) 438-5945

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 363LP0200X | Pediatric Nurse Practitioner | 2667852 | FL | Yes |
| 363LP0200X | Pediatric Nurse Practitioner | 9220069 | FL | — |

## Other

- **Enumeration date:** 09/29/2011
- **Last updated:** 02/19/2014

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 004797600 | — | FL |
| 01 | — | 68-3810 | MEDICARE RHC CERTIFICATION | FL |