Provider Demographics
NPI:1265270490
Name:GORMAN, GWENDOLYN (RD, LDN)
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:GORMAN
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 TOWER PL
Mailing Address - Street 2:
Mailing Address - City:FORT THOMAS
Mailing Address - State:KY
Mailing Address - Zip Code:41075-2136
Mailing Address - Country:US
Mailing Address - Phone:859-760-0830
Mailing Address - Fax:
Practice Address - Street 1:159 TOWER PL
Practice Address - Street 2:
Practice Address - City:FORT THOMAS
Practice Address - State:KY
Practice Address - Zip Code:41075-2136
Practice Address - Country:US
Practice Address - Phone:859-760-0830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-20
Last Update Date:2024-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALDN6891133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered