=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639321342
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WENDI SHARLENE GROTH RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2008
-----------------------------------------------------
Last Update Date | 10/14/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 850 E FOOTHILL BLVD
-----------------------------------------------------
City | RIALTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92376-5230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-421-9255
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 204
-----------------------------------------------------
City | FOREST FALLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92339-0204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-421-9255
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 662801
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163WA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Registered Nurse
-----------------------------------------------------
License Number | 662801
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 163WP0000X
-----------------------------------------------------
Taxonomy Name | Pain Management Registered Nurse
-----------------------------------------------------
License Number | 662801
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 163WP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Registered Nurse
-----------------------------------------------------
License Number | 662801
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------