Basic Information
| Provider Information | |||||||||
| NPI: | 1215121041 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEYO | ||||||||
| FirstName: | GRACE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | CPNP-PC, PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 CHILDRENS DRIVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432052664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147222461 | ||||||||
| FaxNumber: | 6147224565 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 S 18TH ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432052654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147222000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2007 | ||||||||
| LastUpdateDate: | 02/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | APRN.CNP.09603 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363LP0200X | APRN.CNP.09603 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 3015516 | 05 | OH | MEDICAID | H179601 | 01 | OH | CGS-MEDICARE | OTHER |