Provider Demographics
NPI:1912886755
Name:DEYOUNG, GRACE NICHOLE (PA-C)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:NICHOLE
Last Name:DEYOUNG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 PARK STREET
Mailing Address - Street 2:GLENS FALLS HOSPITAL CREDENTIALING
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801
Mailing Address - Country:US
Mailing Address - Phone:518-926-5924
Mailing Address - Fax:
Practice Address - Street 1:79 NORTH STREET
Practice Address - Street 2:GRANVILLE MEDICAL CENTER
Practice Address - City:GRANVILLE
Practice Address - State:NY
Practice Address - Zip Code:12832
Practice Address - Country:US
Practice Address - Phone:518-642-0612
Practice Address - Fax:518-642-0693
Is Sole Proprietor?:No
Enumeration Date:2025-08-27
Last Update Date:2025-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
NY034341363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program