Healthcare Provider Details

I. General information

NPI: 1093212094
Provider Name (Legal Business Name): JESSICA RHAE GROVE MSN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2018
Last Update Date: 03/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 KENT AVE STE 204
CUMBERLAND MD
21502-3799
US

IV. Provider business mailing address

PO BOX 1671
CUMBERLAND MD
21501-1671
US

V. Phone/Fax

Practice location:
  • Phone: 301-777-7300
  • Fax: 301-777-7121
Mailing address:
  • Phone: 240-964-8342
  • Fax: 240-964-8337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP018779
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN691701
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: