Basic Information
| Provider Information | |||||||||
| NPI: | 1922120989 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GROOM | ||||||||
| FirstName: | NORMA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1166 K ST | ||||||||
| Address2: | |||||||||
| City: | BRAWLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922272737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603449951 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 223 W COLE BLVD | ||||||||
| Address2: | |||||||||
| City: | CALEXICO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922319722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603572020 | ||||||||
| FaxNumber: | 7603571056 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2007 | ||||||||
| LastUpdateDate: | 12/20/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | RN255734 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | 255734 | 01 | CA | RN LICENSE | OTHER | 9528 | 01 | CA | RNP | OTHER |