Provider Demographics
NPI:1073170023
Name:GRONDIN, GENNA MARIE (NP)
Entity Type:Individual
Prefix:
First Name:GENNA
Middle Name:MARIE
Last Name:GRONDIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:GENNA
Other - Middle Name:M
Other - Last Name:ORR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:42 N SAINT JOSEPH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-2203
Mailing Address - Country:US
Mailing Address - Phone:696-846-6962
Mailing Address - Fax:269-687-1798
Practice Address - Street 1:42 N SAINT JOSEPH AVE STE 100
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-2203
Practice Address - Country:US
Practice Address - Phone:696-846-6962
Practice Address - Fax:269-687-1798
Is Sole Proprietor?:No
Enumeration Date:2019-05-24
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903237363LF0000X
MI4704386893363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03774317Medicaid