Healthcare Provider Details

I. General information

NPI: 1437805546
Provider Name (Legal Business Name): BRENDA GREGORY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2022
Last Update Date: 02/28/2022
Certification Date: 02/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4105 MEDICAL PKWY STE 207
AUSTIN TX
78756-3725
US

IV. Provider business mailing address

4105 MEDICAL PKWY STE 207
AUSTIN TX
78756-3725
US

V. Phone/Fax

Practice location:
  • Phone: 512-814-7635
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: