Provider Demographics
NPI:1962132860
Name:NICKLAS-MORRIS, GRACE (PA-C)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:NICKLAS-MORRIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 POLO RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-3831
Mailing Address - Country:US
Mailing Address - Phone:336-722-7266
Mailing Address - Fax:336-201-0538
Practice Address - Street 1:1615 POLO RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3831
Practice Address - Country:US
Practice Address - Phone:336-722-7266
Practice Address - Fax:336-201-0538
Is Sole Proprietor?:No
Enumeration Date:2022-06-14
Last Update Date:2025-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-12305363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant