Basic Information
| Provider Information | |||||||||
| NPI: | 1508937004 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GROSE | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 717 FRUITVALE BLVD | ||||||||
| Address2: | |||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989021465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099660199 | ||||||||
| FaxNumber: | 5099664266 | ||||||||
| Practice Location | |||||||||
| Address1: | 717 FRUITVALE BLVD | ||||||||
| Address2: | |||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989021465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099660199 | ||||||||
| FaxNumber: | 5099664266 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 08/29/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | AP30006768 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 8943771 | 01 | WA | CRIME VICTIMS | OTHER | 9066GR | 01 | WA | REGENCE | OTHER | 0194525 | 01 | WA | LABOR AND INDUSTRIES | OTHER | 9645060 | 05 | WA | MEDICAID |