Healthcare Provider Details

I. General information

NPI: 1770344400
Provider Name (Legal Business Name): MACY ANN GRESS LRD, RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2024
Last Update Date: 01/09/2026
Certification Date: 01/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1461 BROADWAY N
FARGO ND
58102-2622
US

IV. Provider business mailing address

2633 55TH ST S APT 217
FARGO ND
58104-9166
US

V. Phone/Fax

Practice location:
  • Phone: 701-293-6037
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1503
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: