Healthcare Provider Details

I. General information

NPI: 1992250302
Provider Name (Legal Business Name): TAYLOR NICOLE GRGURICH RDN, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2016
Last Update Date: 12/20/2022
Certification Date: 12/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3210 SE CORPORATE WOODS DR
ANKENY IA
50021-7405
US

IV. Provider business mailing address

110 S D ST
OSKALOOSA IA
52577-3202
US

V. Phone/Fax

Practice location:
  • Phone: 866-716-3257
  • Fax:
Mailing address:
  • Phone: 641-673-8663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number083778
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: