Provider Demographics
NPI:1326672908
Name:GROW, SOPHIE
Entity Type:Individual
Prefix:
First Name:SOPHIE
Middle Name:
Last Name:GROW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2520 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:PHILOMATH
Mailing Address - State:OR
Mailing Address - Zip Code:97370-9201
Mailing Address - Country:US
Mailing Address - Phone:154-122-1070
Mailing Address - Fax:
Practice Address - Street 1:2520 GREEN ST
Practice Address - Street 2:
Practice Address - City:PHILOMATH
Practice Address - State:OR
Practice Address - Zip Code:97370-9201
Practice Address - Country:US
Practice Address - Phone:154-122-1070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-23
Last Update Date:2020-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR374J00000X
374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula