Provider Demographics
NPI:1265747091
Name:GRAYBEAL, TARA ELAINE (RD)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:ELAINE
Last Name:GRAYBEAL
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 1:10807 E MONTGOMERY DR
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99206-4777
Mailing Address - Country:US
Mailing Address - Phone:509-924-1826
Mailing Address - Fax:509-924-6258
Practice Address - Street 1:10807 E MONTGOMERY DR
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206-4777
Practice Address - Country:US
Practice Address - Phone:509-924-1826
Practice Address - Fax:509-924-6258
Is Sole Proprietor?:No
Enumeration Date:2010-08-17
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI 00001382133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA133V00000XOtherTAXONOMY