Provider Demographics
NPI:1922336619
Name:GROTHJAN, THERESA LEE
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:LEE
Last Name:GROTHJAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5225 E CRYSTAL LN
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-6066
Mailing Address - Country:US
Mailing Address - Phone:949-463-4629
Mailing Address - Fax:
Practice Address - Street 1:5225 E CRYSTAL LN
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-6066
Practice Address - Country:US
Practice Address - Phone:949-463-4629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-18
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN388521163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency