Basic Information
| Provider Information | |||||||||
| NPI: | 1205134152 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRZYBOWSKI | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | JOAN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WALLI | ||||||||
| OtherFirstName: | MELISSA | ||||||||
| OtherMiddleName: | JOAN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3920 13TH AVE E | ||||||||
| Address2: | SUITE 6 | ||||||||
| City: | HIBBING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557463675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182637540 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5219 ST. JOHN'S DRIVE | ||||||||
| Address2: | |||||||||
| City: | NETT LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55772 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2177573650 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2011 | ||||||||
| LastUpdateDate: | 03/02/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 2486 | MN | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.