Healthcare Provider Details

I. General information

NPI: 1619345477
Provider Name (Legal Business Name): MARY GRUSSENDORF
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2015
Last Update Date: 09/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 RESHAW CIR
EVANSVILLE WY
82636-9410
US

IV. Provider business mailing address

721 RESHAW CIR
EVANSVILLE WY
82636-9410
US

V. Phone/Fax

Practice location:
  • Phone: 307-277-5401
  • Fax:
Mailing address:
  • Phone: 307-277-5401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number108766882
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: