Basic Information
| Provider Information | |||||||||
| NPI: | 1124127071 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GROVE | ||||||||
| FirstName: | SUZANNE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 66 N 6TH ST | ||||||||
| Address2: | |||||||||
| City: | POMEROY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993479705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098431591 | ||||||||
| FaxNumber: | 5098431234 | ||||||||
| Practice Location | |||||||||
| Address1: | 66 N 6TH ST | ||||||||
| Address2: | |||||||||
| City: | POMEROY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993479705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098431591 | ||||||||
| FaxNumber: | 5098431234 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 07/13/2010 | ||||||||
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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 | 363LF0000X | AP30000968 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 9604000 | 05 | WA | MEDICAID | 805880200 | 01 | ID | ID DSHS | OTHER | GAB03061 | 01 | WA | MEDICARE PTAN | OTHER |