MEDICARE: NINA GRILLO-BALTHROP MACK MA, NBC-HWC

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
1	171400000X	Health & Wellness Coach

General Provider Information

NPI Number	:	1073212825
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NINA GRILLO-BALTHROP MACK MA, NBC-HWC

Provider Business Mailing Address
First Line	:	1460 BROADWAY FL 16
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10036-7312
Country	:	US
Telephone Number	:	508-410-3305
Fax Number	:

Provider Business Practice Location Address
First Line	:	1460 BROADWAY FL 16
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10036-7312
Country	:	US
Telephone Number	:	508-410-3305
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/01/2023
Last Update Date	:	03/01/2023

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