Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | ME104728 | FL |
NPI | 1003009853 |
---|---|
Provider Name | Grace Dunn |
First Address | High Springs, FL 32643-9669 |
Second Address | Bell, FL 32619-4713 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/08/2007 |
Last Update Date | 15/01/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
002563700 | (05) | FL |
ED473Z | MEDICARE PTAN (01) | FL |