MEDICARE: BLAISE REBECCA GRIESEL MSCN, LN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133N00000X	Nutritionist	NDP-2024-0117	NM

General Provider Information

NPI Number	:	1437970456
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BLAISE REBECCA GRIESEL MSCN, LN

Provider Business Mailing Address
First Line	:	2804 DALLAS ST NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87110-2708
Country	:	US
Telephone Number	:	505-382-3297
Fax Number	:

Provider Business Practice Location Address
First Line	:	2804 DALLAS ST NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87110-2708
Country	:	US
Telephone Number	:	505-382-3297
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/22/2024
Last Update Date	:	10/22/2024

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