Healthcare Provider Details

I. General information

NPI: 1104415926
Provider Name (Legal Business Name): GABRIELLE LONGO MS RDN LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2021
Last Update Date: 01/15/2021
Certification Date: 01/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 E ERIE AVE
PHILADELPHIA PA
19134-1011
US

IV. Provider business mailing address

160 E ERIE AVE
PHILADELPHIA PA
19134-1011
US

V. Phone/Fax

Practice location:
  • Phone: 215-427-8363
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDN006612
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: