Provider Demographics
NPI: | 1851361216 |
---|---|
Name: | GROMER, LAURIE C (CNP) |
Entity Type: | Individual |
Prefix: | |
First Name: | LAURIE |
Middle Name: | C |
Last Name: | GROMER |
Suffix: | |
Gender: | F |
Credentials: | CNP |
Other - Prefix: | |
Other - First Name: | LAURIE |
Other - Middle Name: | C |
Other - Last Name: | KNUTSON |
Other - Suffix: | |
Other - Last Name Type: | Former Name |
Other - Credentials: | CNP |
Mailing Address - Street 1: | PO BOX 5074 |
Mailing Address - Street 2: | |
Mailing Address - City: | SIOUX FALLS |
Mailing Address - State: | SD |
Mailing Address - Zip Code: | 57117-5074 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | 605-339-0309 |
Practice Address - Street 1: | 1309 W 17TH ST |
Practice Address - Street 2: | |
Practice Address - City: | SIOUX FALLS |
Practice Address - State: | SD |
Practice Address - Zip Code: | 57104-4663 |
Practice Address - Country: | US |
Practice Address - Phone: | 605-328-8000 |
Practice Address - Fax: | 605-328-8001 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-01-26 |
Last Update Date: | 2022-05-21 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
SD | CP000445 | 363L00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
SD | 6828010 | Medicaid | |
SD | 2380598 | Other | AMERICAS PPO |
MN | 448690100 | Medicaid | |
SD | 4994407 | Other | BLUE CROSS |
SD | 100634 | Medicare PIN | |
SD | 4994407 | Other | BLUE CROSS |