Provider Demographics
NPI:1609608561
Name:O'GORMAN, GABRIELLE THELMA-ROSE (RD)
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:THELMA-ROSE
Last Name:O'GORMAN
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 1:255 SW 11TH ST APT 1001
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33130-4190
Mailing Address - Country:US
Mailing Address - Phone:814-441-5177
Mailing Address - Fax:
Practice Address - Street 1:255 SW 11TH ST APT 1001
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33130-4190
Practice Address - Country:US
Practice Address - Phone:814-441-5177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-19
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC86265235133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered