Provider Demographics
NPI:1992292551
Name:BEAUCHAMP, GRACE ELIZABETH
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:ELIZABETH
Last Name:BEAUCHAMP
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 1:7 SWISSTONE ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-4105
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:636 MIDDLE COUNTRY RD
Practice Address - Street 2:
Practice Address - City:SELDEN
Practice Address - State:NY
Practice Address - Zip Code:11784-2500
Practice Address - Country:US
Practice Address - Phone:631-707-6223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-19
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY305575363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health