Provider Demographics
NPI:1982203519
Name:KO, GRACE YOUNG (RD)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:YOUNG
Last Name:KO
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 1:15009 NORTHERN BLVD FL 4
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-3888
Mailing Address - Country:US
Mailing Address - Phone:646-272-8492
Mailing Address - Fax:
Practice Address - Street 1:15009 NORTHERN BLVD FL 4
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-3888
Practice Address - Country:US
Practice Address - Phone:646-272-8492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-24
Last Update Date:2020-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered