Healthcare Provider Details

I. General information

NPI: 1396585626
Provider Name (Legal Business Name): BRIANNA KAY MONTROSS MS, RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2024
Last Update Date: 05/30/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 E 9TH ST
CORALVILLE IA
52241-2209
US

IV. Provider business mailing address

817 HUGHES ST
CORALVILLE IA
52241-2143
US

V. Phone/Fax

Practice location:
  • Phone: 319-467-2000
  • Fax:
Mailing address:
  • Phone: 515-402-9674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number110871
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: