Healthcare Provider Details

I. General information

NPI: 1538101795
Provider Name (Legal Business Name): NANCY A GRUBB MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 01/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 31ST AVE SW
PUYALLUP WA
98373-3723
US

IV. Provider business mailing address

3908 10TH ST SE
PUYALLUP WA
98374-2188
US

V. Phone/Fax

Practice location:
  • Phone: 253-848-5951
  • Fax: 253-845-7073
Mailing address:
  • Phone: 253-848-5951
  • Fax: 253-864-8954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00030218
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: