Healthcare Provider Details

I. General information

NPI: 1063711711
Provider Name (Legal Business Name): NORA GEDGAUDAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2011
Last Update Date: 03/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 NW JOHNSON ST SUITE #123
PORTLAND OR
97209-1325
US

IV. Provider business mailing address

1920 NORTH WEST JOHNSON STREET SUITE #123
PORTLAND OR
97209
US

V. Phone/Fax

Practice location:
  • Phone: 503-274-7733
  • Fax: 503-274-7770
Mailing address:
  • Phone: 503-274-7733
  • Fax: 503-274-7770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number000400
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: