Provider Demographics
NPI:1548309917
Name:GRALLA, SUSAN (RD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:GRALLA
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 ROUTE 515
Mailing Address - Street 2:201 B
Mailing Address - City:VERNON
Mailing Address - State:NJ
Mailing Address - Zip Code:07462
Mailing Address - Country:US
Mailing Address - Phone:973-764-1600
Mailing Address - Fax:973-858-0417
Practice Address - Street 1:529 ROUTE 515
Practice Address - Street 2:201 B
Practice Address - City:VERNON
Practice Address - State:NJ
Practice Address - Zip Code:07462
Practice Address - Country:US
Practice Address - Phone:973-764-1600
Practice Address - Fax:973-858-0417
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ929643133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered