Provider Demographics
NPI:1508151507
Name:GROSSKOPF, MARY NOEL (FNP-C)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:NOEL
Last Name:GROSSKOPF
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1345 E ROCKLEDGE RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-6215
Mailing Address - Country:US
Mailing Address - Phone:602-403-1110
Mailing Address - Fax:
Practice Address - Street 1:2915 E BASELINE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2425
Practice Address - Country:US
Practice Address - Phone:480-776-0626
Practice Address - Fax:480-776-0627
Is Sole Proprietor?:No
Enumeration Date:2011-06-17
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP4025363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAP4025OtherSTATE NURSE PRACTIONER LICENSE