Provider Demographics
NPI:1518671320
Name:GROOMS, ANESTY RENEE
Entity Type:Individual
Prefix:
First Name:ANESTY
Middle Name:RENEE
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 1:5414 QUISENBERRY DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45424-4744
Mailing Address - Country:US
Mailing Address - Phone:937-267-0126
Mailing Address - Fax:
Practice Address - Street 1:5414 QUISENBERRY DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45424-4744
Practice Address - Country:US
Practice Address - Phone:937-267-0126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-06
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9999999Medicaid