Provider Demographics
NPI:1699398750
Name:OTUM, GRACE CHIGOZIE (RD, LD)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:CHIGOZIE
Last Name:OTUM
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 1:8787 WOODWAY DR APT 1107
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77063-2424
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1660 KATY GAP RD APT 21106
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77494-7720
Practice Address - Country:US
Practice Address - Phone:205-790-3916
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-24
Last Update Date:2020-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT85863133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered