Healthcare Provider Details

I. General information

NPI: 1407152440
Provider Name (Legal Business Name): GABRIELLE GUIDRY RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2011
Last Update Date: 02/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17307 SE 272ND ST 126
COVINGTON WA
98042-5304
US

IV. Provider business mailing address

23925 225TH WAY SE B
MAPLE VALLEY WA
98038-5233
US

V. Phone/Fax

Practice location:
  • Phone: 253-639-2266
  • Fax: 253-639-8464
Mailing address:
  • Phone: 425-433-0123
  • Fax: 425-433-0733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI60172513
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: