Provider Demographics
NPI:1154571792
Name:CHUPP-GROVE, BARBARA
Entity type:Individual
Prefix:
First Name:BARBARA
Middle Name:
Last Name:CHUPP-GROVE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4049
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4049
Mailing Address - Country:US
Mailing Address - Phone:574-273-6767
Mailing Address - Fax:574-968-7160
Practice Address - Street 1:710 PARK PL
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3519
Practice Address - Country:US
Practice Address - Phone:574-273-6767
Practice Address - Fax:574-968-7160
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-19
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002740A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200928140Medicaid
IN200928140Medicaid