Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 176B00000X | Midwife | 1069315 | TX |
NPI | 1053063651 |
---|---|
Provider Name | Grace Thompson Park |
First Address | Duncanville, TX 75137-2138 |
Second Address | Dallas, TX 75235-7709 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/01/2022 |
Last Update Date | 25/01/2022 |