Provider Demographics
NPI:1053753889
Name:GROOMS-UNRUH, MELINDA (RN)
Entity type:Individual
Prefix:MRS
First Name:MELINDA
Middle Name:
Last Name:GROOMS-UNRUH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:513 E YACOLT RD
Mailing Address - Street 2:PO BOX 291
Mailing Address - City:YACOLT
Mailing Address - State:WA
Mailing Address - Zip Code:98675-5535
Mailing Address - Country:US
Mailing Address - Phone:360-607-6443
Mailing Address - Fax:360-686-8205
Practice Address - Street 1:513 E YACOLT RD
Practice Address - Street 2:
Practice Address - City:YACOLT
Practice Address - State:WA
Practice Address - Zip Code:98675-5535
Practice Address - Country:US
Practice Address - Phone:360-607-6443
Practice Address - Fax:360-686-8205
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-22
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60218267163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA634139Medicaid