Provider Demographics
NPI:1942352463
Name:GRISHAM, SONYA PHILLIPS (MS, RD, LD, CDE)
Entity Type:Individual
Prefix:MRS
First Name:SONYA
Middle Name:PHILLIPS
Last Name:GRISHAM
Suffix:
Gender:F
Credentials:MS, RD, LD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8950 DR MARTIN LUTHER KING JR ST N
Mailing Address - Street 2:STE 101
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-3001
Mailing Address - Country:US
Mailing Address - Phone:727-520-0800
Mailing Address - Fax:727-520-0313
Practice Address - Street 1:8950 DR MARTIN LUTHER KING JR ST N
Practice Address - Street 2:STE 101
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-3001
Practice Address - Country:US
Practice Address - Phone:727-520-0800
Practice Address - Fax:727-520-0313
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL723162133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered