Provider Demographics
NPI:1174087886
Name:TELEPAK, GRACE CHRISTINE
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:CHRISTINE
Last Name:TELEPAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1780 W ASPEN AVE
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85233-3503
Mailing Address - Country:US
Mailing Address - Phone:480-495-4944
Mailing Address - Fax:
Practice Address - Street 1:7500 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-9634
Practice Address - Country:US
Practice Address - Phone:480-495-4944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-27
Last Update Date:2019-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2255A2300X
390200000X
ND2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program