Healthcare Provider Details

I. General information

NPI: 1730837600
Provider Name (Legal Business Name): ERICA GROVE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2022
Last Update Date: 03/30/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10500 MONTGOMERY RD
MONTGOMERY OH
45242-4402
US

IV. Provider business mailing address

1085 SOPHIA DR
MILFORD OH
45150-8040
US

V. Phone/Fax

Practice location:
  • Phone: 253-495-7237
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number0001283973
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0020686
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: