Provider Demographics
NPI:1174915888
Name:GRUBER, NIKKI
Entity type:Individual
Prefix:MRS
First Name:NIKKI
Middle Name:
Last Name:GRUBER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31331 HENSELIN RD
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-6358
Mailing Address - Country:US
Mailing Address - Phone:218-398-5870
Mailing Address - Fax:
Practice Address - Street 1:31331 HENSELIN RD
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-6358
Practice Address - Country:US
Practice Address - Phone:218-398-5870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-04
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNM357417700Medicare UPIN