MEDICARE: KATHY D GRUBE WHNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LW0102X	Women's Health Nurse Practitioner	RN039862NP	GA

General Provider Information

NPI Number	:	1376513960
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHY D GRUBE WHNP

Provider Business Mailing Address
First Line	:	104 CHEROKEE FOREST TRL
Second Line	:
City	:	WARNER ROBINS
State	:	GA
Zip	:	31088-5446
Country	:	US
Telephone Number	:	478-929-8029
Fax Number	:

Provider Business Practice Location Address
First Line	:	1025 N HOUSTON RD
Second Line	:
City	:	WARNER ROBINS
State	:	GA
Zip	:	31093-1505
Country	:	US
Telephone Number	:	478-922-9136
Fax Number	:	478-923-6846

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/25/2006
Last Update Date	:	07/08/2007

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