Provider Demographics
NPI:1205134152
Name:GRZYBOWSKI, MELISSA JOAN
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:JOAN
Last Name:GRZYBOWSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:JOAN
Other - Last Name:WALLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3920 13TH AVE E
Mailing Address - Street 2:SUITE 6
Mailing Address - City:HIBBING
Mailing Address - State:MN
Mailing Address - Zip Code:55746-3675
Mailing Address - Country:US
Mailing Address - Phone:218-263-7540
Mailing Address - Fax:
Practice Address - Street 1:5219 ST. JOHN'S DRIVE
Practice Address - Street 2:
Practice Address - City:NETT LAKE
Practice Address - State:MN
Practice Address - Zip Code:55772
Practice Address - Country:US
Practice Address - Phone:217-757-3650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-02
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2486133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered