Provider Demographics
NPI:1376301085
Name:BURGOS, MICHELLE GRACE (RD)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:GRACE
Last Name:BURGOS
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 1:17520 W GRAND PKWY S.
Mailing Address - Street 2:SUITE110
Mailing Address - City:SUGARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479
Mailing Address - Country:US
Mailing Address - Phone:281-239-3777
Mailing Address - Fax:281-239-3744
Practice Address - Street 1:17520 W GRAND PKWY S.
Practice Address - Street 2:SUITE110
Practice Address - City:SUGARLAND
Practice Address - State:TX
Practice Address - Zip Code:77479
Practice Address - Country:US
Practice Address - Phone:281-239-3777
Practice Address - Fax:281-239-3744
Is Sole Proprietor?:No
Enumeration Date:2024-03-07
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT88436133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered