Healthcare Provider Details

I. General information

NPI: 1952726044
Provider Name (Legal Business Name): PALMER GRAU RD, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2014
Last Update Date: 02/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10605 LONGFELLOW TRCE
SHREVEPORT LA
71106-9363
US

IV. Provider business mailing address

10605 LONGFELLOW TRCE
SHREVEPORT LA
71106-9363
US

V. Phone/Fax

Practice location:
  • Phone: 318-422-0949
  • Fax:
Mailing address:
  • Phone: 318-422-0949
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number935
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: