Individual
GRACE PAE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
111 S 11TH ST, PHILADELPHIA, PA 19107-4824
(732) 284-6690
Mailing address
601 N 2ND ST APT 203, PHILADELPHIA, PA 19123-3076
(732) 284-6690
Taxonomy
Speciality
Code
Description
License number
State
363LA2100X
Acute Care Nurse Practitioner
Primary
SP021485
PA
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
SP033825
PA
Other
Enumeration date
02/26/2020
Last updated
03/25/2026
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