Healthcare Provider Details

I. General information

NPI: 1881246247
Provider Name (Legal Business Name): BARBARA SUE GROSS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2019
Last Update Date: 04/12/2023
Certification Date: 04/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 ZUNI RD SE STE 11
ALBUQUERQUE NM
87108-2935
US

IV. Provider business mailing address

PO BOX 740018
ATLANTA GA
30374-0018
US

V. Phone/Fax

Practice location:
  • Phone: 505-777-3002
  • Fax:
Mailing address:
  • Phone: 773-759-7550
  • Fax: 312-929-0373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number56890
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: