Healthcare Provider Details

I. General information

NPI: 1992955314
Provider Name (Legal Business Name): AMY LOUISE GRUBE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2008
Last Update Date: 08/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 PATTONSVILLE RD
JACKSON OH
45640-9452
US

IV. Provider business mailing address

90 JACKSON PIKE
GALLIPOLIS OH
45631-1560
US

V. Phone/Fax

Practice location:
  • Phone: 740-395-8677
  • Fax: 740-395-8834
Mailing address:
  • Phone: 740-395-8677
  • Fax: 740-395-8834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10237
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP10237
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: