Healthcare Provider Details

I. General information

NPI: 1134313190
Provider Name (Legal Business Name): PATRICIA GOURLAY RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2007
Last Update Date: 09/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4062 W ROYAL DR
TRAVERSE CITY MI
49684-8965
US

IV. Provider business mailing address

4062 W ROYAL DR
TRAVERSE CITY MI
49684-8965
US

V. Phone/Fax

Practice location:
  • Phone: 231-935-0466
  • Fax: 231-935-0467
Mailing address:
  • Phone: 231-935-0466
  • Fax: 231-935-0467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: