Healthcare Provider Details

I. General information

NPI: 1811292469
Provider Name (Legal Business Name): JILL AUBEY GRANNEMAN RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2011
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HOSPITAL DR
COLUMBIA MO
65212-0001
US

IV. Provider business mailing address

2201 W NIFONG BLVD
COLUMBIA MO
65203-9556
US

V. Phone/Fax

Practice location:
  • Phone: 573-771-9888
  • Fax:
Mailing address:
  • Phone: 660-460-5114
  • Fax: 660-851-8006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2009026691
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: