Healthcare Provider Details

I. General information

NPI: 1033279781
Provider Name (Legal Business Name): MARIANNE GRONSTAL CAMPBELL RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5084 AMES AVE
OMAHA NE
68104-2323
US

IV. Provider business mailing address

451 FRANK ST
COUNCIL BLUFFS IA
51503-4551
US

V. Phone/Fax

Practice location:
  • Phone: 402-451-7745
  • Fax: 402-451-8090
Mailing address:
  • Phone: 712-322-7605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number334
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number00025
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: