Provider Demographics
NPI:1104125376
Name:KOVALIK, GRACE GLORIA (LPN)
Entity type:Individual
Prefix:MISS
First Name:GRACE
Middle Name:GLORIA
Last Name:KOVALIK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25532 ROAD 152
Mailing Address - Street 2:
Mailing Address - City:DEXTER
Mailing Address - State:NY
Mailing Address - Zip Code:13634-2162
Mailing Address - Country:US
Mailing Address - Phone:315-639-3640
Mailing Address - Fax:
Practice Address - Street 1:25532 ROAD 152
Practice Address - Street 2:
Practice Address - City:DEXTER
Practice Address - State:NY
Practice Address - Zip Code:13634-2162
Practice Address - Country:US
Practice Address - Phone:315-639-3640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-27
Last Update Date:2011-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY293028-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse