Provider Demographics
NPI:1235735929
Name:BULLOCK, CHELSEA LYN (RDN, LD)
Entity Type:Individual
Prefix:MRS
First Name:CHELSEA
Middle Name:LYN
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:MISS
Other - First Name:CHELSEA
Other - Middle Name:LYN
Other - Last Name:MILLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN, LD
Mailing Address - Street 1:4716 ALLIANCE BLVD STE 310
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-5325
Mailing Address - Country:US
Mailing Address - Phone:469-814-3840
Mailing Address - Fax:
Practice Address - Street 1:4716 ALLIANCE BLVD STE 310
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5325
Practice Address - Country:US
Practice Address - Phone:469-814-3840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86052447133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
86052447OtherCOMMISSION ON DIETETIC REGISTRATION ID