Provider Demographics
NPI:1316589559
Name:GROCHOW, NICOLE LARAY
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:LARAY
Last Name:GROCHOW
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:NICOLE
Other - Middle Name:LARAY
Other - Last Name:WILHOIT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1847
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632
Mailing Address - Country:US
Mailing Address - Phone:360-423-0203
Mailing Address - Fax:360-577-0269
Practice Address - Street 1:720 14TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632
Practice Address - Country:US
Practice Address - Phone:360-423-0203
Practice Address - Fax:360-577-0187
Is Sole Proprietor?:No
Enumeration Date:2019-10-09
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA175T00000X
WACG61011099175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist