Healthcare Provider Details

I. General information

NPI: 1720520315
Provider Name (Legal Business Name): GABRIELLE GRANDELL FMCHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2016
Last Update Date: 08/14/2020
Certification Date: 08/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17000 PRESTON RD STE 400
DALLAS TX
75248-1201
US

IV. Provider business mailing address

120 W CITYLINE DR APT 3048
RICHARDSON TX
75082-3366
US

V. Phone/Fax

Practice location:
  • Phone: 972-930-0260
  • Fax:
Mailing address:
  • Phone: 817-715-0512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: