Provider Demographics
NPI:1841379401
Name:GROTHEM, AVIS L (FNP/CNM)
Entity Type:Individual
Prefix:
First Name:AVIS
Middle Name:L
Last Name:GROTHEM
Suffix:
Gender:F
Credentials:FNP/CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2625
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-2625
Mailing Address - Country:US
Mailing Address - Phone:701-239-7111
Mailing Address - Fax:
Practice Address - Street 1:306 4TH ST N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-4820
Practice Address - Country:US
Practice Address - Phone:701-239-7111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR29668363LX0001X
MNR0772147363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND19747Medicaid
MN527465600Medicaid