Provider Demographics
NPI:1649865262
Name:HARE, GRACIE JEAN
Entity type:Individual
Prefix:
First Name:GRACIE
Middle Name:JEAN
Last Name:HARE
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:P.O. BOX 1122
Mailing Address - Street 2:
Mailing Address - City:MAN
Mailing Address - State:WV
Mailing Address - Zip Code:25635
Mailing Address - Country:US
Mailing Address - Phone:304-702-5256
Mailing Address - Fax:
Practice Address - Street 1:6502 HANGING ROCK HWY
Practice Address - Street 2:
Practice Address - City:LYBURN
Practice Address - State:WV
Practice Address - Zip Code:25632
Practice Address - Country:US
Practice Address - Phone:304-752-5256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-05
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant