Provider Demographics
NPI:1700179371
Name:RENNALLS, GRACE (ARNP)
Entity type:Individual
Prefix:MISS
First Name:GRACE
Middle Name:
Last Name:RENNALLS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6601 SW 62ND AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-3300
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6601 SW 62ND AVE
Practice Address - Street 2:
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-3300
Practice Address - Country:US
Practice Address - Phone:786-466-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-16
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9182186364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health