Provider Demographics
NPI:1225540321
Name:GOMBERT, KELLY ANN (RDN, LDN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:GOMBERT
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:MCGINLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN, LDN
Mailing Address - Street 1:365 FLORA CIR
Mailing Address - Street 2:
Mailing Address - City:LEHIGHTON
Mailing Address - State:PA
Mailing Address - Zip Code:18235-5318
Mailing Address - Country:US
Mailing Address - Phone:484-707-4231
Mailing Address - Fax:
Practice Address - Street 1:656 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:PALMERTON
Practice Address - State:PA
Practice Address - Zip Code:18071-2003
Practice Address - Country:US
Practice Address - Phone:484-707-4231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-30
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN001039133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered