Provider Demographics
NPI:1467567800
Name:GRIM, ANDREA LYNN (RD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:LYNN
Last Name:GRIM
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1303 E HERNDON AVE
Mailing Address - Street 2:MAIL STOP 220
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3309
Mailing Address - Country:US
Mailing Address - Phone:559-450-5166
Mailing Address - Fax:559-450-5473
Practice Address - Street 1:1111 E SPRUCE AVE
Practice Address - Street 2:MAIL STOP 950
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3330
Practice Address - Country:US
Practice Address - Phone:559-450-5166
Practice Address - Fax:559-450-5486
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
837240133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered