Healthcare Provider Details

I. General information

NPI: 1316703663
Provider Name (Legal Business Name): TEARA GRUBER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2024
Last Update Date: 02/26/2024
Certification Date: 02/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10881 YANKEE ST
DAYTON OH
45458-3574
US

IV. Provider business mailing address

3615 SOCIALVILLE FOSTER RD STE C
MASON OH
45040-9054
US

V. Phone/Fax

Practice location:
  • Phone: 513-204-1910
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License NumberRN.371676
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN.CNP.0035921
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: