Healthcare Provider Details

I. General information

NPI: 1629441589
Provider Name (Legal Business Name): GAIL RAVELLO P.H.D. , I.M.D., ND
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2015
Last Update Date: 11/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

490 SUN VALLEY DR SUITE 203
ROSWELL GA
30076-5642
US

IV. Provider business mailing address

490 SUN VALLEY DR SUITE 203
ROSWELL GA
30076-5690
US

V. Phone/Fax

Practice location:
  • Phone: 770-674-6311
  • Fax: 888-551-2391
Mailing address:
  • Phone: 770-674-6311
  • Fax: 888-551-2391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberL-6874975
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License NumberL-6874975
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: