Provider Demographics
NPI:1124161302
Name:HUBBARD, GRACE (MSN, RN, CS)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:HUBBARD
Suffix:
Gender:F
Credentials:MSN, RN, CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3410 CAMBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-4508
Mailing Address - Country:US
Mailing Address - Phone:919-403-1956
Mailing Address - Fax:
Practice Address - Street 1:8520 SIX FORKS RD
Practice Address - Street 2:SUITE 204
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-3095
Practice Address - Country:US
Practice Address - Phone:919-676-1497
Practice Address - Fax:919-676-1430
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200001387175163WP0807X, 163WP0808X, 163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
Not Answered163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Not Answered163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6004003Medicaid