Provider Demographics
NPI:1871303867
Name:ORTIZ, GRACIE MONTALVO (RD, LD)
Entity type:Individual
Prefix:
First Name:GRACIE
Middle Name:MONTALVO
Last Name:ORTIZ
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 1:19317 MOORLYNCH AVE
Mailing Address - Street 2:
Mailing Address - City:PFLUGERVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78660-3457
Mailing Address - Country:US
Mailing Address - Phone:361-549-8252
Mailing Address - Fax:
Practice Address - Street 1:19317 MOORLYNCH AVE
Practice Address - Street 2:
Practice Address - City:PFLUGERVILLE
Practice Address - State:TX
Practice Address - Zip Code:78660-3457
Practice Address - Country:US
Practice Address - Phone:361-549-8252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-10
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT05332133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered