Healthcare Provider Details

I. General information

NPI: 1013522481
Provider Name (Legal Business Name): HUMLIE MEDICAL NUTRITION CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2020
Last Update Date: 09/12/2020
Certification Date: 09/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 W 8TH ST
NEWBERG OR
97132-4603
US

IV. Provider business mailing address

109 W 8TH ST
NEWBERG OR
97132-4603
US

V. Phone/Fax

Practice location:
  • Phone: 503-883-1724
  • Fax: 855-966-4121
Mailing address:
  • Phone: 503-883-1724
  • Fax: 855-966-4121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: GABRIELLE ANASTASIA HUMLIE
Title or Position: OWNER
Credential: RD, LD
Phone: 503-883-1724