Healthcare Provider Details

I. General information

NPI: 1518999853
Provider Name (Legal Business Name): JANA GROSSHEIM CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 02/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 E 30TH ST BLDG A
FARMINGTON NM
87401-8991
US

IV. Provider business mailing address

1515 E 20TH ST STE A
FARMINGTON NM
87401-9039
US

V. Phone/Fax

Practice location:
  • Phone: 505-326-6400
  • Fax: 505-326-4606
Mailing address:
  • Phone: 505-326-6400
  • Fax: 505-326-4606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number54968
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number144782
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: