Organization
GRACE FAMILY PRACTICE CLINIC, P.C.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MONIQUE CASEY-BOLDEN M.D. (PRESIDENT)
(731) 288-0911
Entity
Organization
Contact information
Practice address
1716 PARR AVE STE D, DYERSBURG, TN 38024-2074
(731) 288-0911
(731) 288-0065
Mailing address
1716 PARR AVE STE D, DYERSBURG, TN 38024-2074
(731) 288-0911
(731) 288-0065
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
MD25289
TN
207Q00000X
Family Medicine Physician
Primary
MD35727
TN
363LF0000X
Family Nurse Practitioner
APN13637
TN
Other
Enumeration date
10/09/2017
Last updated
10/09/2017
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