Provider Demographics
NPI:1114430360
Name:GROOMS, ALICE DORINE (RN)
Entity Type:Individual
Prefix:MS
First Name:ALICE
Middle Name:DORINE
Last Name:GROOMS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13001 TAFT RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IL
Mailing Address - Zip Code:61727-2646
Mailing Address - Country:US
Mailing Address - Phone:217-853-1804
Mailing Address - Fax:
Practice Address - Street 1:315 AVENUE F
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-7415
Practice Address - Country:US
Practice Address - Phone:309-267-9449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-09
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041174697163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse