Healthcare Provider Details

I. General information

NPI: 1942526264
Provider Name (Legal Business Name): MARYKAY GROSSMAN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY KATHRYN DAVIS RD

II. Dates (important events)

Enumeration Date: 04/12/2010
Last Update Date: 05/11/2021
Certification Date: 05/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

322 W NORTH RIVER DR
SPOKANE WA
99201-3208
US

IV. Provider business mailing address

322 W NORTH RIVER DR
SPOKANE WA
99201-3208
US

V. Phone/Fax

Practice location:
  • Phone: 509-324-6464
  • Fax: 509-241-2056
Mailing address:
  • Phone: 509-324-6464
  • Fax: 509-241-2056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI00000773
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: