Provider Demographics
NPI:1013675305
Name:GROSE, KRISTIN
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:GROSE
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 1:82 PARMETTA CIR
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:WV
Mailing Address - Zip Code:26184-3349
Mailing Address - Country:US
Mailing Address - Phone:304-966-4697
Mailing Address - Fax:
Practice Address - Street 1:82 PARMETTA CIR
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:WV
Practice Address - Zip Code:26184-3349
Practice Address - Country:US
Practice Address - Phone:304-966-4697
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-03
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV38596164W00000X
OHLPN.176479.MEDS164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse