Healthcare Provider Details

I. General information

NPI: 1659563344
Provider Name (Legal Business Name): MARY SOBNOSKY GROSS MS, RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY B GROSS MS, RD, LDN

II. Dates (important events)

Enumeration Date: 08/16/2007
Last Update Date: 08/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 CONSTITUTION DR
DURHAM NC
27705-2853
US

IV. Provider business mailing address

416 CONSTITUTION DR
DURHAM NC
27705-2853
US

V. Phone/Fax

Practice location:
  • Phone: 919-382-2819
  • Fax: 919-382-2029
Mailing address:
  • Phone: 919-382-2819
  • Fax: 919-382-2029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberL000615
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL000615
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: