Provider Demographics
NPI:1649805102
Name:GORHAM, KATHRYN JANSEN
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:JANSEN
Last Name:GORHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:EILEEN
Other - Last Name:JANSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN
Mailing Address - Street 1:275 S ASPEN ST STOP 89
Mailing Address - Street 2:
Mailing Address - City:BUCKLEY AFB
Mailing Address - State:CO
Mailing Address - Zip Code:80011-9562
Mailing Address - Country:US
Mailing Address - Phone:720-847-6865
Mailing Address - Fax:
Practice Address - Street 1:275 S ASPEN ST STOP 89
Practice Address - Street 2:
Practice Address - City:BUCKLEY AFB
Practice Address - State:CO
Practice Address - Zip Code:80011-9562
Practice Address - Country:US
Practice Address - Phone:720-847-6865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-05
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered