Provider Demographics
NPI:1992955314
Name:GRUBE, AMY LOUISE (FNP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:LOUISE
Last Name:GRUBE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-395-8677
Mailing Address - Fax:740-395-8834
Practice Address - Street 1:280 PATTONSVILLE RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:OH
Practice Address - Zip Code:45640-9452
Practice Address - Country:US
Practice Address - Phone:740-395-8677
Practice Address - Fax:740-395-8834
Is Sole Proprietor?:No
Enumeration Date:2008-09-22
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV10237363LF0000X
OHNP10237363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH310917085217OtherOHIO MEDICAID CARESOURCE
OHP00781887OtherRR MEDICARE
OH2878444OtherOHIO MEDICAID MOLINA
OH2878444Medicaid
WV3810016002Medicaid
OH282601OtherOHIO MEDICAID UNISON
NP82742Medicare PIN