Provider Demographics
NPI:1487127114
Name:GRANT, WANDA LOUISE (REGISTERED DIETITIAN)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:LOUISE
Last Name:GRANT
Suffix:
Gender:F
Credentials:REGISTERED DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8710 CLUBHOUSE BLVD
Mailing Address - Street 2:
Mailing Address - City:DESERT HOT SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92240-1166
Mailing Address - Country:US
Mailing Address - Phone:760-668-9289
Mailing Address - Fax:
Practice Address - Street 1:8710 CLUBHOUSE BLVD
Practice Address - Street 2:
Practice Address - City:DESERT HOT SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92240-1166
Practice Address - Country:US
Practice Address - Phone:760-668-9289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-04
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA413840133V00000X
WA413840133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered