Provider Demographics
NPI:1053173823
Name:GROSKREUTZ, MOLLY JEAN (CRNP)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:JEAN
Last Name:GROSKREUTZ
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4705 MEADOW POND LN
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-2287
Mailing Address - Country:US
Mailing Address - Phone:608-790-7714
Mailing Address - Fax:
Practice Address - Street 1:4705 MEADOW POND LN
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-2287
Practice Address - Country:US
Practice Address - Phone:608-790-7714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-26
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61506091363LA2200X
OR10021602363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health