Provider Demographics
NPI:1790481828
Name:MISKELLY, GRACE LONDON (RDN, LD)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:LONDON
Last Name:MISKELLY
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5065 AMESBURY DR APT 315
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-4629
Mailing Address - Country:US
Mailing Address - Phone:601-502-3990
Mailing Address - Fax:
Practice Address - Street 1:1935 MEDICAL DISTRICT DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7701
Practice Address - Country:US
Practice Address - Phone:844-424-4537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-31
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT88126133V00000X, 133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric