Provider Demographics
NPI:1295871614
Name:GORMLEY, DONNA JEAN (RD)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:JEAN
Last Name:GORMLEY
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 1:1401 N 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:STAYTON
Mailing Address - State:OR
Mailing Address - Zip Code:97383-1311
Mailing Address - Country:US
Mailing Address - Phone:503-769-4380
Mailing Address - Fax:503-769-8563
Practice Address - Street 1:1401 N 10TH AVE
Practice Address - Street 2:
Practice Address - City:STAYTON
Practice Address - State:OR
Practice Address - Zip Code:97383-1311
Practice Address - Country:US
Practice Address - Phone:503-769-4380
Practice Address - Fax:503-769-8563
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR772133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered