Provider Demographics
NPI:1508442658
Name:GROSS, MARIE E (RN)
Entity Type:Individual
Prefix:MRS
First Name:MARIE
Middle Name:E
Last Name:GROSS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 242
Mailing Address - Street 2:
Mailing Address - City:TIMBER LAKE
Mailing Address - State:SD
Mailing Address - Zip Code:57656-0242
Mailing Address - Country:US
Mailing Address - Phone:605-848-0134
Mailing Address - Fax:
Practice Address - Street 1:24276 166TH STREET AIRPORT ROAD
Practice Address - Street 2:
Practice Address - City:EAGLE BUTTE
Practice Address - State:SD
Practice Address - Zip Code:57625
Practice Address - Country:US
Practice Address - Phone:605-964-7724
Practice Address - Fax:605-964-1342
Is Sole Proprietor?:No
Enumeration Date:2021-03-19
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR030777163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care