Provider Demographics
NPI:1144628041
Name:GRACE, DEL
Entity type:Individual
Prefix:
First Name:DEL
Middle Name:
Last Name:GRACE
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:DEL
Other - Middle Name:M
Other - Last Name:GRACE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PNP, DNP
Mailing Address - Street 1:1850 S WATERMAN AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-2877
Mailing Address - Country:US
Mailing Address - Phone:909-890-9393
Mailing Address - Fax:
Practice Address - Street 1:1850 S WATERMAN AVE
Practice Address - Street 2:SUITE F
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-2877
Practice Address - Country:US
Practice Address - Phone:909-890-9393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-09
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN348835363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics