Provider Demographics
NPI:1801226634
Name:BALLOW, MAYNON MICHELLE (CLINICAL NUTRITION/B)
Entity Type:Individual
Prefix:MS
First Name:MAYNON
Middle Name:MICHELLE
Last Name:BALLOW
Suffix:
Gender:F
Credentials:CLINICAL NUTRITION/B
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4707 PURDUE AVENUE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75209
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4209 MCKINNEY AVENUE SUITE 202-C
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75207
Practice Address - Country:US
Practice Address - Phone:214-641-8885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-14
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103TH0004X, 133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic