Provider Demographics
NPI:1124337993
Name:COLEY, GRACE LAINE (LPN)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:LAINE
Last Name:COLEY
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 1:41 SUSAN LANE
Mailing Address - Street 2:APT. 4
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14616-4910
Mailing Address - Country:US
Mailing Address - Phone:585-563-7190
Mailing Address - Fax:
Practice Address - Street 1:41 SUSAN LN
Practice Address - Street 2:APT. 4
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14616-4910
Practice Address - Country:US
Practice Address - Phone:585-563-7190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-28
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY297187-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse