Provider Demographics
NPI:1760520399
Name:GORMAN, MICHELE ANN (MS, RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:ANN
Last Name:GORMAN
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 WILLOW ST
Mailing Address - Street 2:ST 220
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55403-2269
Mailing Address - Country:US
Mailing Address - Phone:612-240-4196
Mailing Address - Fax:
Practice Address - Street 1:1409 WILLOW ST
Practice Address - Street 2:ST 220
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55403-2269
Practice Address - Country:US
Practice Address - Phone:612-240-4196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-04
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2244133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered