Provider Demographics
NPI:1508583329
Name:GROOMS, AMY DAWN
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:DAWN
Last Name:GROOMS
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 1:10593 LONG JOHN SILVER TRL
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45133-7302
Mailing Address - Country:US
Mailing Address - Phone:937-205-9774
Mailing Address - Fax:
Practice Address - Street 1:10593 LONG JOHN SILVER TRL
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OH
Practice Address - Zip Code:45133-7302
Practice Address - Country:US
Practice Address - Phone:937-205-9774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH402115641018376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH71968750Medicaid