Provider Demographics
NPI:1689338444
Name:GROAH, AMANDA ROSELLE (LVN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ROSELLE
Last Name:GROAH
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:MRS
Other - First Name:AMANDA
Other - Middle Name:ROSELLE
Other - Last Name:BAUGUS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LVN
Mailing Address - Street 1:1816 DURANGO CT
Mailing Address - Street 2:
Mailing Address - City:TULARE
Mailing Address - State:CA
Mailing Address - Zip Code:93274-8566
Mailing Address - Country:US
Mailing Address - Phone:559-368-8926
Mailing Address - Fax:
Practice Address - Street 1:1816 DURANGO CT
Practice Address - Street 2:
Practice Address - City:TULARE
Practice Address - State:CA
Practice Address - Zip Code:93274-8566
Practice Address - Country:US
Practice Address - Phone:559-368-8926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-27
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA210077164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse