Provider Demographics
NPI:1316586720
Name:WATHEN, GRACE
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:WATHEN
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 1:200 WINCHESTER CIR APT C107
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-1861
Mailing Address - Country:US
Mailing Address - Phone:831-588-1355
Mailing Address - Fax:
Practice Address - Street 1:1225 CRANE ST STE 201
Practice Address - Street 2:
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-4253
Practice Address - Country:US
Practice Address - Phone:831-588-1355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-02
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18517171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist