Healthcare Provider Details

I. General information

NPI: 1104178896
Provider Name (Legal Business Name): JENIFER L GROOMS CRNP, APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2012
Last Update Date: 11/12/2025
Certification Date: 11/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3925 N GATEWAY DR
APPLETON WI
54913-7863
US

IV. Provider business mailing address

3 NEENAH CTR
NEENAH WI
54956-3070
US

V. Phone/Fax

Practice location:
  • Phone: 920-702-6371
  • Fax: 920-993-5037
Mailing address:
  • Phone: 920-830-5900
  • Fax: 920-830-5910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number14116
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberSP012418
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11005606
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: