Provider Demographics
NPI:1659889152
Name:CASTILLO, MIRANDA LEIGH (RDN, CDE)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:LEIGH
Last Name:CASTILLO
Suffix:
Gender:F
Credentials:RDN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16111 IKE LN
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:TX
Mailing Address - Zip Code:78154-1154
Mailing Address - Country:US
Mailing Address - Phone:361-813-8810
Mailing Address - Fax:
Practice Address - Street 1:16111 IKE LN
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:TX
Practice Address - Zip Code:78154-1154
Practice Address - Country:US
Practice Address - Phone:361-813-8810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-18
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT84930133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered