Basic Information
| Provider Information | |||||||||
| NPI: | 1598146706 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GROTHAUS | ||||||||
| FirstName: | THRESA | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | MS, APRN, CPNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 308 TAFT ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS GROVE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458301122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196592829 | ||||||||
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| Practice Location | |||||||||
| Address1: | 214 TOWN CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | VAN WERT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458919086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192322323 | ||||||||
| FaxNumber: | 4192382322 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2015 | ||||||||
| LastUpdateDate: | 01/17/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | RN246505 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0133929 | 05 | OH | MEDICAID |