Provider Demographics
NPI:1982938346
Name:GORHAM, PAULA DAUGHERTY (LD)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:DAUGHERTY
Last Name:GORHAM
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18108 PROVIDENCE AVE
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-4142
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4300 W MEMORIAL RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8304
Practice Address - Country:US
Practice Address - Phone:405-752-3640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-01
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKLD163133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered