Healthcare Provider Details

I. General information

NPI: 1083203616
Provider Name (Legal Business Name): BOBBIE BERNA GROOM RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2021
Last Update Date: 01/18/2021
Certification Date: 01/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18110 SE 34TH ST
VANCOUVER WA
98683-9418
US

IV. Provider business mailing address

18110 SE 34TH ST
VANCOUVER WA
98683-9418
US

V. Phone/Fax

Practice location:
  • Phone: 800-330-3665
  • Fax:
Mailing address:
  • Phone: 800-330-3665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number093000424RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: