Provider Demographics
NPI:1942619465
Name:GILLINGHAM, SIMONE (RD, LD)
Entity Type:Individual
Prefix:
First Name:SIMONE
Middle Name:
Last Name:GILLINGHAM
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:SIMONE
Other - Middle Name:
Other - Last Name:CHAMPAGNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD
Mailing Address - Street 1:3115 ALAMEDA ST APT 15
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-9677
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8495 CRATER LAKE HWY
Practice Address - Street 2:MAIL STOP 10
Practice Address - City:WHITE CITY
Practice Address - State:OR
Practice Address - Zip Code:97503-3011
Practice Address - Country:US
Practice Address - Phone:541-826-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-08
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLDD10153903133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered