Healthcare Provider Details

I. General information

NPI: 1992920516
Provider Name (Legal Business Name): DEBRA RUTH GROMLEY NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2220 N MONROE ST SUITE 1
DECATUR IL
62526-6304
US

IV. Provider business mailing address

504 W JACKSON ST
SULLIVAN IL
61951-1360
US

V. Phone/Fax

Practice location:
  • Phone: 217-875-1886
  • Fax: 217-875-3120
Mailing address:
  • Phone: 217-728-4943
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number209000998
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: