Healthcare Provider Details

I. General information

NPI: 1497996953
Provider Name (Legal Business Name): TAMRA LEIGH GROODE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2009
Last Update Date: 03/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 MARTIN LUTHER KING JR WAY
BERKELEY CA
94703-2165
US

IV. Provider business mailing address

2701 MARTIN LUTHER KING JR WAY
BERKELEY CA
94703
US

V. Phone/Fax

Practice location:
  • Phone: 510-644-6095
  • Fax:
Mailing address:
  • Phone: 510-644-6095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number18331
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: