Provider Demographics
NPI:1083699763
Name:GROSSMAN, ELAINE TIZZ (MS, RD)
Entity Type:Individual
Prefix:MS
First Name:ELAINE
Middle Name:TIZZ
Last Name:GROSSMAN
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:STURGIS STREET BLDG. 1145
Mailing Address - Street 2:BOX 788250
Mailing Address - City:TWENTYNINE PALMS
Mailing Address - State:CA
Mailing Address - Zip Code:92278-8250
Mailing Address - Country:US
Mailing Address - Phone:760-830-2120
Mailing Address - Fax:
Practice Address - Street 1:STURGIS STREET BLDG. 1145
Practice Address - Street 2:BOX 788250
Practice Address - City:TWENTYNINE PALMS
Practice Address - State:CA
Practice Address - Zip Code:92278-8250
Practice Address - Country:US
Practice Address - Phone:760-830-2120
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
700227OtherNATIONAL CERTIFICATION