Provider Demographics
NPI:1164022919
Name:MOORE, GRACE ELLEN (RDN)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:ELLEN
Last Name:MOORE
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 N VALENTINE ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84116-3627
Mailing Address - Country:US
Mailing Address - Phone:443-299-9623
Mailing Address - Fax:
Practice Address - Street 1:5126 W DAYBREAK PKWY
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84009-5994
Practice Address - Country:US
Practice Address - Phone:443-299-9623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-30
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD86051484133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty