Provider Demographics
NPI:1083443824
Name:GRACE, KELLY (CRNP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GRACE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 N WHITE HORSE PIKE
Mailing Address - Street 2:
Mailing Address - City:HAMMONTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08037-1896
Mailing Address - Country:US
Mailing Address - Phone:609-652-1000
Mailing Address - Fax:609-441-8178
Practice Address - Street 1:219 N WHITE HORSE PIKE
Practice Address - Street 2:
Practice Address - City:HAMMONTON
Practice Address - State:NJ
Practice Address - Zip Code:08037
Practice Address - Country:US
Practice Address - Phone:609-652-1000
Practice Address - Fax:609-441-8178
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-30
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP029843363LF0000X
NJ26NJ15144700363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily