Individual
GRACE KENVILLE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
5501 OLD YORK RD, PHILADELPHIA, PA 19141-3018
(215) 456-7890
Mailing address
24 SAXONY DR, CINNAMINSON, NJ 08077-4390
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
MA066123
PA
Other
Enumeration date
10/08/2024
Last updated
10/08/2024
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