Provider Demographics
NPI:1356837579
Name:GREVENGOED, MICHAEL WAYNE (CNP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WAYNE
Last Name:GREVENGOED
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:DOON
Mailing Address - State:IA
Mailing Address - Zip Code:51235-7726
Mailing Address - Country:US
Mailing Address - Phone:605-496-1502
Mailing Address - Fax:
Practice Address - Street 1:800 OAK ST
Practice Address - Street 2:
Practice Address - City:SHELDON
Practice Address - State:IA
Practice Address - Zip Code:51201-1242
Practice Address - Country:US
Practice Address - Phone:712-324-5356
Practice Address - Fax:712-324-6515
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA127289363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily