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NPI Code Detail

MEDICARE: MRS. JILL LYNETTE GRIESBAUM MS, RD

MEDICARE: MRS. JILL LYNETTE GRIESBAUM MS, RD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1133V00000XRegistered Dietitian553528MO

General Provider Information

NPI Number : 1003837162
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. JILL LYNETTE GRIESBAUM MS, RD
Provider Business Mailing Address
First Line : 600 N MAIN ST
Second Line :
City : MOUNT VERNON
State : MO
Zip : 65712-1004
Country : US
Telephone Number : 417-466-0187
Fax Number :
Provider Business Practice Location Address
First Line : 600 N MAIN ST
Second Line :
City : MOUNT VERNON
State : MO
Zip : 65712-1004
Country : US
Telephone Number : 417-466-0187
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/22/2006
Last Update Date : 07/08/2007

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