Healthcare Provider Details

I. General information

NPI: 1841910866
Provider Name (Legal Business Name): MOLLY K GRIFFIN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2022
Last Update Date: 08/30/2022
Certification Date: 08/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2265 COMO AVE
SAINT PAUL MN
55108-1737
US

IV. Provider business mailing address

5424 CHICAGO AVE
MINNEAPOLIS MN
55417-2444
US

V. Phone/Fax

Practice location:
  • Phone: 651-645-5323
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number4796
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: