Provider Demographics
NPI:1518617182
Name:GAMBLE, ELYCE MEGAN (MS, CD, RD)
Entity Type:Individual
Prefix:
First Name:ELYCE
Middle Name:MEGAN
Last Name:GAMBLE
Suffix:
Gender:F
Credentials:MS, CD, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1871 S 1030 W
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84058-8141
Mailing Address - Country:US
Mailing Address - Phone:509-294-6931
Mailing Address - Fax:
Practice Address - Street 1:1871 S 1030 W
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-8141
Practice Address - Country:US
Practice Address - Phone:509-294-6931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-26
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12705609-4901133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered