Provider Demographics
NPI:1366578999
Name:GOOD, GRACE ANN (NP)
Entity type:Individual
Prefix:MRS
First Name:GRACE ANN
Middle Name:
Last Name:GOOD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 FRUIT ST
Mailing Address - Street 2:BIGELOW 1034
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2621
Mailing Address - Country:US
Mailing Address - Phone:617-724-3277
Mailing Address - Fax:617-643-1384
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:BIGELOW 1034
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-724-3277
Practice Address - Fax:617-643-1384
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA109082363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP3901OtherBLUE SHIELD
MANP3901OtherBLUE SHIELD
MAP67090Medicare UPIN