Provider Demographics
NPI:1831866367
Name:GROMMON, MAGGIE J (APNP FNP-BC)
Entity type:Individual
Prefix:
First Name:MAGGIE
Middle Name:J
Last Name:GROMMON
Suffix:
Gender:F
Credentials:APNP FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:752 N HIGH POINT RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53717-2236
Mailing Address - Country:US
Mailing Address - Phone:608-824-4000
Mailing Address - Fax:608-824-4917
Practice Address - Street 1:752 N HIGH POINT RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53717-2236
Practice Address - Country:US
Practice Address - Phone:608-824-4000
Practice Address - Fax:608-824-4917
Is Sole Proprietor?:No
Enumeration Date:2021-08-24
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11244-33363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1831866367Medicaid