Provider Demographics
NPI:1144203191
Name:GORMAN, MARYANN (RD)
Entity Type:Individual
Prefix:MS
First Name:MARYANN
Middle Name:
Last Name:GORMAN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 CHERRY LN
Mailing Address - Street 2:
Mailing Address - City:FLORAL PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11001-1300
Mailing Address - Country:US
Mailing Address - Phone:781-268-9598
Mailing Address - Fax:516-488-3749
Practice Address - Street 1:98120 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-4357
Practice Address - Country:US
Practice Address - Phone:718-268-9598
Practice Address - Fax:516-488-3749
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-23
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003481133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY164460OtherELDERPLAN
NYP2706184OtherOXFORD
NYP2706184OtherOXFORD