Provider Demographics
NPI:1962084558
Name:STANGER, GRACE ROSE
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:ROSE
Last Name:STANGER
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 1:730 WILDWOOD RD APT 305
Mailing Address - Street 2:
Mailing Address - City:MAHTOMEDI
Mailing Address - State:MN
Mailing Address - Zip Code:55115-2292
Mailing Address - Country:US
Mailing Address - Phone:651-231-7348
Mailing Address - Fax:
Practice Address - Street 1:730 WILDWOOD RD APT 305
Practice Address - Street 2:
Practice Address - City:MAHTOMEDI
Practice Address - State:MN
Practice Address - Zip Code:55115-2292
Practice Address - Country:US
Practice Address - Phone:651-231-7348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-23
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other