Healthcare Provider Details

I. General information

NPI: 1306472782
Provider Name (Legal Business Name): MARY JOYCE GRUBER CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2020
Last Update Date: 03/18/2020
Certification Date: 03/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 10TH ST W FL 41514
SAINT PAUL MN
55102-1062
US

IV. Provider business mailing address

45 10TH ST W FL 4151
SAINT PAUL MN
55102-1062
US

V. Phone/Fax

Practice location:
  • Phone: 651-232-3340
  • Fax:
Mailing address:
  • Phone: 651-232-3340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License Number119
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: