Healthcare Provider Details

I. General information

NPI: 1023020005
Provider Name (Legal Business Name): CAROLYN JO GRZENDA RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

1400 BLACKHORSE HILL RD
COATESVILLE PA
19320-2040
US

IV. Provider business mailing address

1400 BLACKHORSE HILL RD
COATESVILLE PA
19320-2040
US

V. Phone/Fax

Practice location:
  • Phone: 610-384-7711
  • Fax:
Mailing address:
  • Phone: 610-384-7711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDN001910
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: