Provider Demographics
NPI:1235717059
Name:GRANT, MARINA (CNS)
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18117 BISCAYNE BLVD # 1176
Mailing Address - Street 2:
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33160-2535
Mailing Address - Country:US
Mailing Address - Phone:786-571-0909
Mailing Address - Fax:786-661-2804
Practice Address - Street 1:18117 BISCAYNE BLVD # 1176
Practice Address - Street 2:
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33160-2535
Practice Address - Country:US
Practice Address - Phone:786-571-0909
Practice Address - Fax:786-661-2804
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-01
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10293133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty