Provider Demographics
NPI:1538896915
Name:GRANT, CAROLINA (RDN)
Entity type:Individual
Prefix:
First Name:CAROLINA
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:CAROLINA
Other - Middle Name:
Other - Last Name:GRANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:GASTELUM ZARAGOZA
Mailing Address - Street 1:7500 N DREAMY DRAW DR STE 145
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-4668
Mailing Address - Country:US
Mailing Address - Phone:480-882-4545
Mailing Address - Fax:480-882-5814
Practice Address - Street 1:4131 N 24TH ST STE B102
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-6231
Practice Address - Country:US
Practice Address - Phone:480-882-4545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-04
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ86106922133V00000X
L-305659174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No174N00000XOther Service ProvidersLactation Consultant, Non-RN
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ150093Medicaid