Provider Demographics
NPI:1104690122
Name:MASAKADZA, GRACE
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:MASAKADZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 COUNTRY VIEW WAY
Mailing Address - Street 2:
Mailing Address - City:TELFORD
Mailing Address - State:PA
Mailing Address - Zip Code:18969-1338
Mailing Address - Country:US
Mailing Address - Phone:267-640-6113
Mailing Address - Fax:
Practice Address - Street 1:124 COUNTRY VIEW WAY
Practice Address - Street 2:
Practice Address - City:TELFORD
Practice Address - State:PA
Practice Address - Zip Code:18969-1338
Practice Address - Country:US
Practice Address - Phone:267-640-6113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-09
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP028528363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology