Provider Demographics
NPI:1982953196
Name:GRANT, LYNN MARGARET (RD, LD, CDE)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:MARGARET
Last Name:GRANT
Suffix:
Gender:F
Credentials:RD, LD, CDE
Other - Prefix:
Other - First Name:LYNN
Other - Middle Name:MARGARET
Other - Last Name:EATON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD
Mailing Address - Street 1:PO BOX 1128
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65102-1128
Mailing Address - Country:US
Mailing Address - Phone:573-632-5093
Mailing Address - Fax:573-632-5857
Practice Address - Street 1:1432 SOUTHWEST BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-2444
Practice Address - Country:US
Practice Address - Phone:573-632-5093
Practice Address - Fax:573-632-5857
Is Sole Proprietor?:No
Enumeration Date:2012-09-04
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012028920133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered