Healthcare Provider Details

I. General information

NPI: 1861978421
Provider Name (Legal Business Name): CELESTE DELAINE GROTHUSEN APRN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2018
Last Update Date: 07/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3510 N RIDGE RD STE 100
WICHITA KS
67205-1210
US

IV. Provider business mailing address

3510 N RIDGE RD STE 100
WICHITA KS
67205-1210
US

V. Phone/Fax

Practice location:
  • Phone: 316-269-3223
  • Fax: 316-269-3328
Mailing address:
  • Phone: 316-269-3223
  • Fax: 316-269-3328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number78246
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number78246
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: