Provider Demographics
NPI:1124578133
Name:GROVE, MICHELLE DAWN (RD)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:DAWN
Last Name:GROVE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MISS
Other - First Name:MICHELLE
Other - Middle Name:DAWN
Other - Last Name:UNDERWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:PO BOX 1398
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-0309
Mailing Address - Country:US
Mailing Address - Phone:509-527-8000
Mailing Address - Fax:509-527-8226
Practice Address - Street 1:1025 S 2ND AVE
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-4116
Practice Address - Country:US
Practice Address - Phone:509-527-8000
Practice Address - Fax:509-527-8226
Is Sole Proprietor?:No
Enumeration Date:2016-10-13
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI60659124133V00000X
ORLD-D-10176576133V00000X
PADN005221133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered