Provider Demographics
NPI:1831485770
Name:GRAMLICH, JUDEANA AMM (FNP)
Entity Type:Individual
Prefix:MISS
First Name:JUDEANA
Middle Name:AMM
Last Name:GRAMLICH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MRS
Other - First Name:JUDEANA
Other - Middle Name:ANN
Other - Last Name:FOGLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:10 MEDICAL PARK
Mailing Address - Street 2:SUITE 104
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003
Mailing Address - Country:US
Mailing Address - Phone:304-242-4800
Mailing Address - Fax:304-242-3580
Practice Address - Street 1:10 MEDICAL PARK
Practice Address - Street 2:SUITE 104
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003
Practice Address - Country:US
Practice Address - Phone:304-242-4800
Practice Address - Fax:304-242-3580
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.12579-NP363LF0000X
WVAPRN58557363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0053716Medicaid