Provider Demographics
NPI:1780431890
Name:GRANT, ROSALIE OLIVIA
Entity type:Individual
Prefix:
First Name:ROSALIE
Middle Name:OLIVIA
Last Name:GRANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8412 CALDER AVE SE
Mailing Address - Street 2:
Mailing Address - City:DELANO
Mailing Address - State:MN
Mailing Address - Zip Code:55328-8015
Mailing Address - Country:US
Mailing Address - Phone:612-876-2677
Mailing Address - Fax:
Practice Address - Street 1:8412 CALDER AVE SE
Practice Address - Street 2:
Practice Address - City:DELANO
Practice Address - State:MN
Practice Address - Zip Code:55328-8015
Practice Address - Country:US
Practice Address - Phone:612-876-2677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5238133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty