Basic Information
| Provider Information | |||||||||
| NPI: | 1740678945 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELY | ||||||||
| FirstName: | CATHERINE | ||||||||
| MiddleName: | LEAH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RDN, LD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MILLBURG | ||||||||
| OtherFirstName: | CATHERINE | ||||||||
| OtherMiddleName: | LEAH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RDN, LD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 305 NE LOOP 820 | ||||||||
| Address2: | BUSINESS TOWER 1, SUITE 200 | ||||||||
| City: | HURST | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760537209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172928787 | ||||||||
| FaxNumber: | 8177896849 | ||||||||
| Practice Location | |||||||||
| Address1: | 920 SHILOH ROAD | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9039392800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2014 | ||||||||
| LastUpdateDate: | 12/23/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | DT83400 | TX | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.