Provider Demographics
NPI:1225410665
Name:PHELON, GRACE (MDA, RD, LD)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:PHELON
Suffix:
Gender:F
Credentials:MDA, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 18TH ST
Mailing Address - Street 2:
Mailing Address - City:SPIRIT LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:51360-1026
Mailing Address - Country:US
Mailing Address - Phone:712-336-4900
Mailing Address - Fax:
Practice Address - Street 1:1500 18TH ST
Practice Address - Street 2:
Practice Address - City:SPIRIT LAKE
Practice Address - State:IA
Practice Address - Zip Code:51360-1026
Practice Address - Country:US
Practice Address - Phone:712-336-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-22
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA078676133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered