Healthcare Provider Details

I. General information

NPI: 1821435413
Provider Name (Legal Business Name): BARBARA RUTH GRANSTROM BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2013
Last Update Date: 05/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 SAINT ANDREW ST
LA CROSSE WI
54603-3301
US

IV. Provider business mailing address

417 S COURT ST
SPARTA WI
54656-1718
US

V. Phone/Fax

Practice location:
  • Phone: 608-785-6266
  • Fax:
Mailing address:
  • Phone: 608-269-4847
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number76752-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: