Provider Demographics
NPI:1124127071
Name:GROVE, SUZANNE M (ARNP)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:M
Last Name:GROVE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:POMEROY
Mailing Address - State:WA
Mailing Address - Zip Code:99347-9705
Mailing Address - Country:US
Mailing Address - Phone:509-843-1591
Mailing Address - Fax:509-843-1234
Practice Address - Street 1:66 N 6TH ST
Practice Address - Street 2:
Practice Address - City:POMEROY
Practice Address - State:WA
Practice Address - Zip Code:99347-9705
Practice Address - Country:US
Practice Address - Phone:509-843-1591
Practice Address - Fax:509-843-1234
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30000968363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9604000Medicaid
ID805880200OtherID DSHS
WAGAB03061OtherMEDICARE PTAN
WA9604000Medicaid