Healthcare Provider Details

I. General information

NPI: 1194367128
Provider Name (Legal Business Name): GRACIE MICHELLE DULICK MS, RDN, CSP, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2019
Last Update Date: 05/11/2023
Certification Date: 05/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 E BANNOCK ST
BOISE ID
83712-6241
US

IV. Provider business mailing address

3608 S WILLIAMSBURG WAY
BOISE ID
83706-5604
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-3421
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License NumberD-1218
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: