Provider Demographics
NPI:1508508151
Name:AVERY-GRANT, ANIKA LYNETTE
Entity Type:Individual
Prefix:
First Name:ANIKA
Middle Name:LYNETTE
Last Name:AVERY-GRANT
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 1:2471 PLUM CREEK LN
Mailing Address - Street 2:
Mailing Address - City:ROAMING SHORES
Mailing Address - State:OH
Mailing Address - Zip Code:44084-9687
Mailing Address - Country:US
Mailing Address - Phone:440-668-1710
Mailing Address - Fax:
Practice Address - Street 1:54 E COLONY DR
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43566-8723
Practice Address - Country:US
Practice Address - Phone:440-668-1710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-12
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD.3857133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered