Provider Demographics
NPI:1841585841
Name:GROOMS, KEVIN L (CRNP)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:L
Last Name:GROOMS
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5947 HIGHWAY 269
Mailing Address - Street 2:
Mailing Address - City:PARRISH
Mailing Address - State:AL
Mailing Address - Zip Code:35580
Mailing Address - Country:US
Mailing Address - Phone:205-686-5113
Mailing Address - Fax:205-686-5145
Practice Address - Street 1:5947 HIGHWAY 269
Practice Address - Street 2:
Practice Address - City:PARRISH
Practice Address - State:AL
Practice Address - Zip Code:35580
Practice Address - Country:US
Practice Address - Phone:205-686-5113
Practice Address - Fax:205-686-5145
Is Sole Proprietor?:No
Enumeration Date:2011-06-17
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1076162363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL167059Medicaid
AL511-55403OtherBLUE CROSS OF ALABAMA
AL511-55403OtherBLUE CROSS OF ALABAMA