Provider Demographics
NPI:1992105894
Name:MAINA, GRACE
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:MAINA
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 1:1104 HIDDEN RDG APT 2005
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-7973
Mailing Address - Country:US
Mailing Address - Phone:469-226-1159
Mailing Address - Fax:
Practice Address - Street 1:1104 HIDDEN RDG APT 2005
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-7973
Practice Address - Country:US
Practice Address - Phone:469-226-1159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-27
Last Update Date:2014-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX126399363LP2300X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics