Basic Information
| Provider Information | |||||||||
| NPI: | 1720692007 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HUMLIE | ||||||||
| FirstName: | GABRIELLE | ||||||||
| MiddleName: | ANASTASIA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KENT | ||||||||
| OtherFirstName: | GABRIELLE | ||||||||
| OtherMiddleName: | ANASTASIA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2435 NE CUMULUS AVE STE A | ||||||||
| Address2: | |||||||||
| City: | MCMINNVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971288805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034726161 | ||||||||
| FaxNumber: | 5034346290 | ||||||||
| Practice Location | |||||||||
| Address1: | 2435 NE CUMULUS AVE STE A | ||||||||
| Address2: | |||||||||
| City: | MCMINNVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971288805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034726161 | ||||||||
| FaxNumber: | 5034346290 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2020 | ||||||||
| LastUpdateDate: | 10/17/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | LD-D-10209651 | OR | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.