Provider Demographics
NPI:1316692445
Name:GROVEUNDER, LEEANN RENE (FNP-C)
Entity type:Individual
Prefix:
First Name:LEEANN
Middle Name:RENE
Last Name:GROVEUNDER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10860 EAST LADYBUG PLACE
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86315-3307
Mailing Address - Country:US
Mailing Address - Phone:951-505-8218
Mailing Address - Fax:
Practice Address - Street 1:10860 E LADY BUG LN
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86315-4861
Practice Address - Country:US
Practice Address - Phone:951-505-8218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-17
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ274014363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program