MEDICARE: MAYCIE GROTH PNP

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	363LP0200X	Pediatric Nurse Practitioner	AP144427	TX

General Provider Information

NPI Number	:	1437727989
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAYCIE GROTH PNP

Provider Business Mailing Address
First Line	:	PO BOX 1908
Second Line	:
City	:	GREENVILLE
State	:	TX
Zip	:	75403-1908
Country	:	US
Telephone Number	:	903-454-3025
Fax Number	:	903-450-1408

Provider Business Practice Location Address
First Line	:	2600 COMMERCE WAY
Second Line	:
City	:	KAUFMAN
State	:	TX
Zip	:	75142-7325
Country	:	US
Telephone Number	:	972-750-3177
Fax Number	:

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

Provider Enumeration Date	:	06/11/2021
Last Update Date	:	06/11/2021

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