Basic Information
| Provider Information | |||||||||
| NPI: | 1639841810 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GROSS | ||||||||
| FirstName: | JANESSA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24664 SWEET MEADOWS DR | ||||||||
| Address2: | |||||||||
| City: | HERMOSA | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577445102 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 353 FAIRMONT BLVD | ||||||||
| Address2: | |||||||||
| City: | RAPID CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577017375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6057558222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2021 | ||||||||
| LastUpdateDate: | 10/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | CP002166 | SD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.