Healthcare Provider Details

I. General information

NPI: 1124602081
Provider Name (Legal Business Name): GRETCHEN JEAN GEROVAC NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2021
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

257 W SAINT GEORGE AVE
GRANTSBURG WI
54840-7827
US

IV. Provider business mailing address

257 W SAINT GEORGE AVE
GRANTSBURG WI
54840-7827
US

V. Phone/Fax

Practice location:
  • Phone: 715-463-5353
  • Fax:
Mailing address:
  • Phone: 715-463-5353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number8158
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number11896
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: