Healthcare Provider Details

I. General information

NPI: 1518569268
Provider Name (Legal Business Name): ELIZABETH GAYNOR MASTER'S OF SCIENCE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2020
Last Update Date: 11/09/2020
Certification Date: 11/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 NE RUSSELL ST STE 201
PORTLAND OR
97212-3763
US

IV. Provider business mailing address

10407 SE 24TH AVE
MILWAUKIE OR
97222-7519
US

V. Phone/Fax

Practice location:
  • Phone: 646-234-2882
  • Fax:
Mailing address:
  • Phone: 646-234-2882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: