Provider Demographics
NPI:1710627633
Name:GALLARDO, SIERRA (RD)
Entity Type:Individual
Prefix:
First Name:SIERRA
Middle Name:
Last Name:GALLARDO
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 1:5514 E 300 N
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-7899
Mailing Address - Country:US
Mailing Address - Phone:765-490-0144
Mailing Address - Fax:
Practice Address - Street 1:5514 E 300 N
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-7899
Practice Address - Country:US
Practice Address - Phone:765-490-0144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-30
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH09722133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered