Healthcare Provider Details

I. General information

NPI: 1518793447
Provider Name (Legal Business Name): AMANDA RASHELLE GROMMESCH BSN, RN, PHN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2024
Last Update Date: 08/14/2025
Certification Date: 08/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 VETERANS DR
SAINT CLOUD MN
56303-2015
US

IV. Provider business mailing address

64 LINDEN AVE S
MAPLE LAKE MN
55358-4580
US

V. Phone/Fax

Practice location:
  • Phone: 320-252-1670
  • Fax:
Mailing address:
  • Phone: 952-994-5126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number2481723
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code364SC1501X
TaxonomyCommunity Health/Public Health Clinical Nurse Specialist
License Number32572
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2481723
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: