Provider Demographics
NPI:1154412625
Name:GRACE, AMY NICOLE (MD)
Entity type:Individual
Prefix:DR
First Name:AMY
Middle Name:NICOLE
Last Name:GRACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4720 S I-10 SERVICE RD
Mailing Address - Street 2:STE 502
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70001
Mailing Address - Country:US
Mailing Address - Phone:504-885-6060
Mailing Address - Fax:504-887-2114
Practice Address - Street 1:4720 S I-10 SERVICE RD
Practice Address - Street 2:STE 502
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70001
Practice Address - Country:US
Practice Address - Phone:504-885-6060
Practice Address - Fax:504-887-2114
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD200156207V00000X
AL25113207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAP00459229OtherRAILROAD MEDICARE
LA200156OtherSTATE
LA32593OtherCDS
LA1626775Medicaid
LA1626775Medicaid
LA4J789DB64Medicare PIN
I36385Medicare UPIN
LA4J789CK41Medicare PIN