Healthcare Provider Details

I. General information

NPI: 1851118186
Provider Name (Legal Business Name): KATIE GRUMBIR RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2024
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2905 NORTHWEST BLVD STE 230
PLYMOUTH MN
55441-2644
US

IV. Provider business mailing address

2905 NORTHWEST BLVD STE 230
PLYMOUTH MN
55441-2644
US

V. Phone/Fax

Practice location:
  • Phone: 612-367-4824
  • Fax:
Mailing address:
  • Phone: 612-367-4824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number3174
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: