Provider Demographics
NPI:1346790300
Name:BALLEW, GRACE (RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:GRACE
Middle Name:
Last Name:BALLEW
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9386 S 278TH EAST AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-4305
Mailing Address - Country:US
Mailing Address - Phone:405-334-2101
Mailing Address - Fax:
Practice Address - Street 1:12697 E 51ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146-6236
Practice Address - Country:US
Practice Address - Phone:918-505-3201
Practice Address - Fax:919-505-3258
Is Sole Proprietor?:No
Enumeration Date:2016-10-13
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK86020939133V00000X
OK2088133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered