Provider Demographics
NPI:1104146133
Name:GRACE, JOLIETTE NICOLE (MD)
Entity type:Individual
Prefix:DR
First Name:JOLIETTE
Middle Name:NICOLE
Last Name:GRACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JOLIETTE
Other - Middle Name:NICOLE
Other - Last Name:BARNUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:13111 BRIDGEPORT XING
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34211-4002
Mailing Address - Country:US
Mailing Address - Phone:573-703-5663
Mailing Address - Fax:
Practice Address - Street 1:200 HERLONG AVE S STE G
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1182
Practice Address - Country:US
Practice Address - Phone:803-909-6300
Practice Address - Fax:803-909-6310
Is Sole Proprietor?:No
Enumeration Date:2010-06-01
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC93469208600000X
FLME133013208600000X, 2086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery