Provider Demographics
NPI:1609176882
Name:GRANT, CAROLE (RD,LD,CNSC)
Entity Type:Individual
Prefix:MS
First Name:CAROLE
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:RD,LD,CNSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1081 E CEDAR RIDGE RUN
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901-7308
Mailing Address - Country:US
Mailing Address - Phone:928-338-3647
Mailing Address - Fax:928-338-3522
Practice Address - Street 1:200 WEST HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:WHITERIVER
Practice Address - State:AZ
Practice Address - Zip Code:85941
Practice Address - Country:US
Practice Address - Phone:928-338-3647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-22
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD003592133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic