Healthcare Provider Details

I. General information

NPI: 1578091237
Provider Name (Legal Business Name): AMANDA MARIE GROVE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2017
Last Update Date: 05/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 4TH AVE SE
CEDAR RAPIDS IA
52403-2425
US

IV. Provider business mailing address

5420 TARENA CT SW
CEDAR RAPIDS IA
52404-7327
US

V. Phone/Fax

Practice location:
  • Phone: 319-298-2200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA131009
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: