Provider Demographics
NPI:1366107534
Name:DENNIS, GRACE SHEPHERD
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:SHEPHERD
Last Name:DENNIS
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 1:676 CLYMER SHERMAN RD
Mailing Address - Street 2:
Mailing Address - City:CLYMER
Mailing Address - State:NY
Mailing Address - Zip Code:14724-9758
Mailing Address - Country:US
Mailing Address - Phone:716-499-5167
Mailing Address - Fax:
Practice Address - Street 1:2 W CRESCENT PARK
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:PA
Practice Address - Zip Code:16365-2199
Practice Address - Country:US
Practice Address - Phone:814-723-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-03
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical