Provider Demographics
NPI:1801420245
Name:MYGRANT, CORY (MS, RDN)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:
Last Name:MYGRANT
Suffix:
Gender:F
Credentials:MS, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9347 PENDLETON PIKE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46236-2768
Mailing Address - Country:US
Mailing Address - Phone:260-359-2444
Mailing Address - Fax:
Practice Address - Street 1:9347 PENDLETON PIKE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46236-2768
Practice Address - Country:US
Practice Address - Phone:260-359-2444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-25
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN86061086133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered