Provider Demographics
NPI:1992920516
Name:GROMLEY, DEBRA RUTH (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:RUTH
Last Name:GROMLEY
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:IL
Mailing Address - Zip Code:61951-1360
Mailing Address - Country:US
Mailing Address - Phone:217-728-4943
Mailing Address - Fax:
Practice Address - Street 1:2220 N MONROE ST
Practice Address - Street 2:SUITE 1
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-6304
Practice Address - Country:US
Practice Address - Phone:217-875-1886
Practice Address - Fax:217-875-3120
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209000998363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG84217Medicare UPIN