Provider Demographics
NPI:1467681668
Name:CHANG, GRACE (RD)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:CHANG
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 1:1515 JOHN ST
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-2560
Mailing Address - Country:US
Mailing Address - Phone:201-613-4844
Mailing Address - Fax:
Practice Address - Street 1:1515 JOHN ST
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-2560
Practice Address - Country:US
Practice Address - Phone:201-613-4844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-08
Last Update Date:2009-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ872369133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered