Provider Demographics
NPI:1457756272
Name:OTTOMANELLI, GRACE-MARIE MARTINA (PA-C)
Entity type:Individual
Prefix:
First Name:GRACE-MARIE
Middle Name:MARTINA
Last Name:OTTOMANELLI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
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Mailing Address - Street 1:2425 FARGO BLVD
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-3591
Mailing Address - Country:US
Mailing Address - Phone:630-232-2200
Mailing Address - Fax:630-232-1940
Practice Address - Street 1:2425 FARGO BLVD
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-3591
Practice Address - Country:US
Practice Address - Phone:630-232-2200
Practice Address - Fax:630-232-1940
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-23
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.005311363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant