Provider Demographics
NPI:1508849076
Name:GROTH, MARY ELIZABETH (APRN, PMHS)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:GROTH
Suffix:
Gender:F
Credentials:APRN, PMHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 589
Mailing Address - Street 2:59 LYME STREET
Mailing Address - City:OLD LYME
Mailing Address - State:CT
Mailing Address - Zip Code:06371
Mailing Address - Country:US
Mailing Address - Phone:860-373-6208
Mailing Address - Fax:860-434-1580
Practice Address - Street 1:59 LYME STREET
Practice Address - Street 2:
Practice Address - City:OLD LYME
Practice Address - State:CT
Practice Address - Zip Code:06371
Practice Address - Country:US
Practice Address - Phone:860-373-6208
Practice Address - Fax:860-434-1580
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001632363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004200391Medicaid
P11997Medicare UPIN
CT500000859Medicare ID - Type Unspecified