Healthcare Provider Details

I. General information

NPI: 1013386929
Provider Name (Legal Business Name): JUSTIN GROCE APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2015
Last Update Date: 02/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 WINWOOD DR SUITE 105
LEBANON TN
37087-1340
US

IV. Provider business mailing address

115 WINWOOD DR SUITE 105
LEBANON TN
37087-1340
US

V. Phone/Fax

Practice location:
  • Phone: 615-444-4126
  • Fax: 855-785-2890
Mailing address:
  • Phone: 615-444-4126
  • Fax: 855-785-2890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number20598
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: