Basic Information
| Provider Information | |||||||||
| NPI: | 1558340349 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MISAKI | ||||||||
| FirstName: | GRACE | ||||||||
| MiddleName: | I. | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1835 SAVOY DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303411072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704969400 | ||||||||
| FaxNumber: | 7704969495 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 PROFESSIONAL DR # A | ||||||||
| Address2: | SUITE 260 | ||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708220788 | ||||||||
| FaxNumber: | 7708220326 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2006 | ||||||||
| LastUpdateDate: | 05/25/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN098265 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 000852057E | 05 | GA | MEDICAID |