{
"Npi": {
"NPI": "1326450479",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "N",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "GRONBECK",
"FirstName": "NICOLE",
"MiddleName": null,
"NamePrefix": "MRS.",
"NameSuffix": null,
"Credential": "A.T.C.",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": "CALLAGHAN",
"OtherFirstName": "NICOLE",
"OtherMiddleName": null,
"OtherNamePrefix": "MRS.",
"OtherNameSuffix": null,
"OtherCredential": "A.T.C.",
"OtherLastNameTypeCode": "1",
"FirstLineMailingAddress": "110 ELM ST APT. 3D",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "WESTWOOD",
"MailingAddressStateName": "NJ",
"MailingAddressPostalCode": "07675",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "914-769-8311",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "825 WESTLAKE DR",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "THORNWOOD",
"PracticeLocationAddressStateName": "NY",
"PracticeLocationAddressPostalCode": "10594-1945",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "914-769-8311",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "05/23/2014",
"LastUpdateDate": "04/15/2024",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "F",
"Gender": "Female",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "2255A2300X",
"TaxonomyName": "Athletic Trainer",
"LicenseNumber": "25MT00166800",
"LicenseNumberStateCode": "NJ",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "2255A2300X",
"TaxonomyName": "Athletic Trainer",
"LicenseNumber": "002004-1",
"LicenseNumberStateCode": "NY",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}