Provider Demographics
NPI:1891248704
Name:GRUBB, BROOKE DIANNA (RD, LD)
Entity Type:Individual
Prefix:MISS
First Name:BROOKE
Middle Name:DIANNA
Last Name:GRUBB
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 RIVERFRONT DR
Mailing Address - Street 2:APT 239
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72202-2208
Mailing Address - Country:US
Mailing Address - Phone:573-450-9625
Mailing Address - Fax:
Practice Address - Street 1:1101 S TENNESSEE ST
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71601-5801
Practice Address - Country:US
Practice Address - Phone:870-543-2380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-27
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1519133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered