Healthcare Provider Details

I. General information

NPI: 1144203191
Provider Name (Legal Business Name): MARYANN GORMAN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 01/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98120 QUEENS BLVD
REGO PARK NY
11374-4357
US

IV. Provider business mailing address

202 CHERRY LN
FLORAL PARK NY
11001-1300
US

V. Phone/Fax

Practice location:
  • Phone: 718-268-9598
  • Fax: 516-488-3749
Mailing address:
  • Phone: 781-268-9598
  • Fax: 516-488-3749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number003481
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: