Provider Demographics
NPI:1316280845
Name:GRACE, HALEY BETH (RD, LD)
Entity type:Individual
Prefix:
First Name:HALEY
Middle Name:BETH
Last Name:GRACE
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 1:29 MITYLENE PARK LN
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-7303
Mailing Address - Country:US
Mailing Address - Phone:334-356-2061
Mailing Address - Fax:334-356-2694
Practice Address - Street 1:29 MITYLENE PARK LN
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-7303
Practice Address - Country:US
Practice Address - Phone:334-356-2061
Practice Address - Fax:334-356-2694
Is Sole Proprietor?:No
Enumeration Date:2013-04-03
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT82658133V00000X
AL2879133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered