Provider Demographics
NPI:1336502343
Name:CRUZ-GROTH, CHRISTINE LAURA
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:LAURA
Last Name:CRUZ-GROTH
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:US DEPT OFSTATE
Mailing Address - Street 2:M/MED/QI, SA-1
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20522-0102
Mailing Address - Country:US
Mailing Address - Phone:202-663-1519
Mailing Address - Fax:202-663-3247
Practice Address - Street 1:M MED QI SA 1
Practice Address - Street 2:US DEPT OF STATE
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20522-0102
Practice Address - Country:US
Practice Address - Phone:202-663-1519
Practice Address - Fax:202-663-3247
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-29
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23414363LF0000X
VA0001257807363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily