Provider Demographics
NPI:1669179339
Name:GRIGG, LYSHELL (REGISTERED DIETITIAN)
Entity type:Individual
Prefix:
First Name:LYSHELL
Middle Name:
Last Name:GRIGG
Suffix:
Gender:F
Credentials:REGISTERED DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5568 S CAPER PL
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716-6929
Mailing Address - Country:US
Mailing Address - Phone:208-488-8653
Mailing Address - Fax:
Practice Address - Street 1:5568 S CAPER PL
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83716-6929
Practice Address - Country:US
Practice Address - Phone:208-488-8653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-1106133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty