Provider Demographics
NPI:1689043408
Name:GROTH, JACQUELINE (APRN FNP-C)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:GROTH
Suffix:
Gender:F
Credentials:APRN FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 MONTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-2912
Mailing Address - Country:US
Mailing Address - Phone:330-321-9849
Mailing Address - Fax:
Practice Address - Street 1:18697 BAGLEY RD
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44130-3497
Practice Address - Country:US
Practice Address - Phone:440-816-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-22
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH397399163W00000X
OHAPRN.CNP.0029732363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse