Provider Demographics
NPI:1487699294
Name:YELLAND, GRACE VIVONA (MD)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:VIVONA
Last Name:YELLAND
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:CAROL
Other - Last Name:VIVONA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 850
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-0146
Mailing Address - Country:US
Mailing Address - Phone:360-457-8578
Mailing Address - Fax:360-457-4841
Practice Address - Street 1:303 W 8TH ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-5904
Practice Address - Country:US
Practice Address - Phone:360-457-8578
Practice Address - Fax:360-457-4841
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00029053208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8196982Medicaid
WA189669OtherLABOR & INDUSTRIES
WA189669OtherLABOR & INDUSTRIES
WA8196982Medicaid