MEDICARE: TRICIA NICOLE GRONDIN RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WG0000X	General Practice Registered Nurse	R0117751	OK

General Provider Information

NPI Number	:	1295687770
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRICIA NICOLE GRONDIN RN

Provider Business Mailing Address
First Line	:	12017 E 109TH ST N
Second Line	:
City	:	OWASSO
State	:	OK
Zip	:	74055-7466
Country	:	US
Telephone Number	:	626-377-0617
Fax Number	:

Provider Business Practice Location Address
First Line	:	12017 E 109TH ST N
Second Line	:
City	:	OWASSO
State	:	OK
Zip	:	74055-7466
Country	:	US
Telephone Number	:	626-377-0617
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/09/2026
Last Update Date	:	02/09/2026

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