Provider Demographics
NPI:1487175048
Name:KELLEY, GRACE
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:KELLEY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 CONGRESS AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78701-3692
Mailing Address - Country:US
Mailing Address - Phone:888-663-6331
Mailing Address - Fax:
Practice Address - Street 1:319 CONGRESS AVE STE 100
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701-3692
Practice Address - Country:US
Practice Address - Phone:888-663-6331
Practice Address - Fax:415-252-7176
Is Sole Proprietor?:No
Enumeration Date:2017-07-03
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY718665-1163W00000X
MI4704335813363LF0000X
TX1132148363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse