Provider Demographics
NPI:1497800239
Name:O'GORMAN, MARTHA MARY (MS,RD,LDN)
Entity Type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:MARY
Last Name:O'GORMAN
Suffix:
Gender:F
Credentials:MS,RD,LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 W ALDEN PL
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-4311
Mailing Address - Country:US
Mailing Address - Phone:815-758-0082
Mailing Address - Fax:
Practice Address - Street 1:125 NORTH FIRST STREET
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-4311
Practice Address - Country:US
Practice Address - Phone:815-761-4280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist