Provider Demographics
NPI:1407151921
Name:GROTH, BONNIE L (NP)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:L
Last Name:GROTH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:BONNIE
Other - Middle Name:L
Other - Last Name:KIHNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:801 BROADWAY N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-3641
Mailing Address - Country:US
Mailing Address - Phone:701-234-2251
Mailing Address - Fax:
Practice Address - Street 1:801 BROADWAY N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-3641
Practice Address - Country:US
Practice Address - Phone:701-234-2251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-13
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR30800363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND84048Medicaid
ND84048Medicaid
NDN716388Medicare PIN