1093767352 NPI number — GRACE NORTHRUP FNP-BC

Table of content: GRACE NORTHRUP FNP-BC (NPI 1093767352)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093767352 NPI number — GRACE NORTHRUP FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NORTHRUP
Provider First Name:
GRACE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NORTHRUP
Provider Other First Name:
GRACE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LTC, AN, FNP-C
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1093767352
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4494 PALMER RD. N.
Provider Second Line Business Mailing Address:
BLDG 10, NURSING ADMINISTRATION
Provider Business Mailing Address City Name:
BETHESDA
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20814
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4494 PALMER RD. N.
Provider Second Line Business Practice Location Address:
BLDG 10, NURSING ADMINISTRATION
Provider Business Practice Location Address City Name:
BETHESDA
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20814
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-295-4800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  R129200 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: R129200 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 400068400 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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