Provider Demographics
NPI:1942526264
Name:GROSSMAN, MARYKAY (RD)
Entity type:Individual
Prefix:
First Name:MARYKAY
Middle Name:
Last Name:GROSSMAN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:KATHRYN
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:322 W NORTH RIVER DR
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-3208
Mailing Address - Country:US
Mailing Address - Phone:509-324-6464
Mailing Address - Fax:509-241-2056
Practice Address - Street 1:322 W NORTH RIVER DR
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-3208
Practice Address - Country:US
Practice Address - Phone:509-324-6464
Practice Address - Fax:509-241-2056
Is Sole Proprietor?:No
Enumeration Date:2010-04-12
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00000773133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered