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General NPI Number Information
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NPI Number | 1497800239
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Entity Type | Individual
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Provider Name | MARTHA MARY O'GORMAN M.S.,R.D.,L.D.N.
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Gender | Female
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Dates
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Enumeration Date | 01/24/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 125 NORTH FIRST STREET
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City | DEKALB
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State | IL
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Zip | 60115-4311
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Country | US
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Telephone | 815-761-4280
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Fax |
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Provider Business Mailing Address
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Address Line | 121 W ALDEN PL
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City | DEKALB
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State | IL
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Zip | 60115-4311
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Country | US
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Telephone | 815-758-0082
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133N00000X
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Taxonomy Name | Nutritionist
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License Number |
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License Number State | IL
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