Provider Demographics
NPI:1366614745
Name:GRACE, SALLY MALONEY (ARNP)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:MALONEY
Last Name:GRACE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2699
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32513-2699
Mailing Address - Country:US
Mailing Address - Phone:850-416-7619
Mailing Address - Fax:850-416-7753
Practice Address - Street 1:5149 N 9TH AVE
Practice Address - Street 2:SUITE 254
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8756
Practice Address - Country:US
Practice Address - Phone:850-416-7619
Practice Address - Fax:850-416-7753
Is Sole Proprietor?:No
Enumeration Date:2008-03-26
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1025132363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY124GOtherBLUE SHIELD
FL309118000OtherMEDICAID
FLAK269ZMedicare PIN