Provider Demographics
NPI:1124687280
Name:GRACYK, KATHIE N
Entity type:Individual
Prefix:
First Name:KATHIE
Middle Name:N
Last Name:GRACYK
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 1:515 W COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-4401
Mailing Address - Country:US
Mailing Address - Phone:805-315-7093
Mailing Address - Fax:
Practice Address - Street 1:1301 N A ST
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-3516
Practice Address - Country:US
Practice Address - Phone:805-742-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN517760163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool