Provider Demographics
NPI:1992702666
Name:GROVE, SUSAN M (FNP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:GROVE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:91 PERIMETER RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13441-4018
Mailing Address - Country:US
Mailing Address - Phone:315-336-8260
Mailing Address - Fax:315-337-3807
Practice Address - Street 1:91 PERIMETER RD
Practice Address - Street 2:SUITE 120
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13441-4018
Practice Address - Country:US
Practice Address - Phone:315-336-8260
Practice Address - Fax:315-337-3807
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF331849363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02195260Medicaid
NYP14536Medicare UPIN
NY02195260Medicaid