Healthcare Provider Details

I. General information

NPI: 1992973218
Provider Name (Legal Business Name): MARY MELINDA GRISWOLD APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2008
Last Update Date: 06/13/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 31ST ST
WILSON KS
67490-8740
US

IV. Provider business mailing address

611 31ST ST
WILSON KS
67490-8740
US

V. Phone/Fax

Practice location:
  • Phone: 785-761-6505
  • Fax:
Mailing address:
  • Phone: 785-761-6865
  • Fax: 620-792-7052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number53-75175-012
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code163WC1400X
TaxonomyCollege Health Registered Nurse
License Number13-91537-012
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: