Healthcare Provider Details

I. General information

NPI: 1205134152
Provider Name (Legal Business Name): MELISSA JOAN GRZYBOWSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELISSA JOAN WALLI

II. Dates (important events)

Enumeration Date: 03/02/2011
Last Update Date: 03/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5219 ST. JOHN'S DRIVE
NETT LAKE MN
55772
US

IV. Provider business mailing address

3920 13TH AVE E SUITE 6
HIBBING MN
55746-3675
US

V. Phone/Fax

Practice location:
  • Phone: 217-757-3650
  • Fax:
Mailing address:
  • Phone: 218-263-7540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2486
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: