Provider Demographics
NPI:1659462752
Name:GROSSMILLER, GWEN (RD)
Entity Type:Individual
Prefix:MS
First Name:GWEN
Middle Name:
Last Name:GROSSMILLER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 ST CHARLES AVE
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-5526
Mailing Address - Country:US
Mailing Address - Phone:928-442-1054
Mailing Address - Fax:
Practice Address - Street 1:500 N HWY 89
Practice Address - Street 2:NORTHERN ARIZONA VA HCS
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86313
Practice Address - Country:US
Practice Address - Phone:928-445-4860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered