Provider Demographics
NPI:1780399402
Name:TEGENKAMP, GRACE SYDNEY (OD)
Entity type:Individual
Prefix:DR
First Name:GRACE
Middle Name:SYDNEY
Last Name:TEGENKAMP
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5328 N DAVIS HWY
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-2006
Mailing Address - Country:US
Mailing Address - Phone:850-434-6387
Mailing Address - Fax:850-432-0540
Practice Address - Street 1:5328 N DAVIS HWY
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2006
Practice Address - Country:US
Practice Address - Phone:850-434-6387
Practice Address - Fax:850-432-0540
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-17
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC6182152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty