Provider Demographics
NPI:1457695595
Name:GROTH, NICOLE B (ARNP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:B
Last Name:GROTH
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 1:1303 NW ABBIE DR
Mailing Address - Street 2:
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50023-9391
Mailing Address - Country:US
Mailing Address - Phone:515-314-7869
Mailing Address - Fax:
Practice Address - Street 1:13435 UNIVERSITY AVE STE 500
Practice Address - Street 2:
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-8251
Practice Address - Country:US
Practice Address - Phone:515-225-7132
Practice Address - Fax:515-218-1500
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA-119130363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1457695595Medicaid
IAP01141261OtherRR MEDICARE
IAP01141261OtherRR MEDICARE