Healthcare Provider Details

I. General information

NPI: 1669913349
Provider Name (Legal Business Name): LAURA GRUBB NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2017
Last Update Date: 12/21/2021
Certification Date: 12/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 E MASON ST STE. 4P57
SPRINGFIELD IL
62701-1034
US

IV. Provider business mailing address

619 E MASON ST STE. 4P57
SPRINGFIELD IL
62701-1034
US

V. Phone/Fax

Practice location:
  • Phone: 217-788-0706
  • Fax: 217-525-2535
Mailing address:
  • Phone: 217-788-0706
  • Fax: 217-525-2535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number209.015752
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.015752
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: