Provider Demographics
NPI:1619213089
Name:PETERS, GRACE ELIZABETH (LAC)
Entity type:Individual
Prefix:MISS
First Name:GRACE
Middle Name:ELIZABETH
Last Name:PETERS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5324 NE 32ND PL
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-6836
Mailing Address - Country:US
Mailing Address - Phone:714-269-4273
Mailing Address - Fax:
Practice Address - Street 1:530 NW 23RD AVE STE 111
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3287
Practice Address - Country:US
Practice Address - Phone:714-269-4273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-12
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC160462171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist