Healthcare Provider Details

I. General information

NPI: 1366858136
Provider Name (Legal Business Name): DIANA MARIE GRUSHAN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2014
Last Update Date: 07/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2855 VALMONT RD
BOULDER CO
80301-1309
US

IV. Provider business mailing address

2886 LA GRANGE CIR
BOULDER CO
80305-6339
US

V. Phone/Fax

Practice location:
  • Phone: 303-442-5160
  • Fax: 303-440-8769
Mailing address:
  • Phone: 720-252-2149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License Number0060277
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: