Organization
GRACE PEDIATRICS PL
Active
Organization subpart
No
Provider details
NPI number
Authorized official
COLLEEN THOMPSON (MANAGER/ARNP/CO-OWNER)
(386) 243-8474
Entity
Organization
Contact information
Practice address
4196 W US HIGHWAY 90, SUITE 105, LAKE CITY, FL 32055-8834
(386) 243-8474
(386) 438-5945
Mailing address
4196 W US HIGHWAY 90, SUITE 105, LAKE CITY, FL 32055-8834
(386) 243-8474
(386) 438-5945
Taxonomy
Speciality
Code
Description
License number
State
363LP0200X
Pediatric Nurse Practitioner
Primary
2667852
FL
363LP0200X
Pediatric Nurse Practitioner
9220069
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
004797600
—
FL
01
—
68-3810
MEDICARE RHC CERTIFICATION
FL
Enumeration date
09/29/2011
Last updated
02/19/2014
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