Provider Demographics
NPI:1528315785
Name:GRACE, ANNETTE RUTH (PA-C)
Entity type:Individual
Prefix:MS
First Name:ANNETTE
Middle Name:RUTH
Last Name:GRACE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:ANNETTE
Other - Middle Name:RUTH
Other - Last Name:SCHULTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:73 LINDEN AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45403-1934
Mailing Address - Country:US
Mailing Address - Phone:937-401-9120
Mailing Address - Fax:
Practice Address - Street 1:1 ELIZABETH PL
Practice Address - Street 2:STE. D
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-3445
Practice Address - Country:US
Practice Address - Phone:937-222-2233
Practice Address - Fax:937-222-9665
Is Sole Proprietor?:No
Enumeration Date:2012-08-07
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50002335363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical