Healthcare Provider Details

I. General information

NPI: 1366035156
Provider Name (Legal Business Name): EMILIE M GROVE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2021
Last Update Date: 06/25/2024
Certification Date: 06/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 JAMESTOWN BLVD BLDG 200
WATKINSVILLE GA
30677-4131
US

IV. Provider business mailing address

PO BOX 48089
ATHENS GA
30604-8089
US

V. Phone/Fax

Practice location:
  • Phone: 706-769-0005
  • Fax: 706-769-0403
Mailing address:
  • Phone: 706-389-3740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberRN269803
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: