Provider Demographics
NPI:1063269967
Name:GONZALEZ, LORENA (RDN)
Entity type:Individual
Prefix:
First Name:LORENA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 METHOW ST S #2
Mailing Address - Street 2:PO BOX 493
Mailing Address - City:TWISP
Mailing Address - State:WA
Mailing Address - Zip Code:98856
Mailing Address - Country:US
Mailing Address - Phone:865-404-0491
Mailing Address - Fax:
Practice Address - Street 1:417 METHOW ST S #2
Practice Address - Street 2:PO BOX 493
Practice Address - City:TWISP
Practice Address - State:WA
Practice Address - Zip Code:98856
Practice Address - Country:US
Practice Address - Phone:865-404-0491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-30
Last Update Date:2025-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLDN000004807133V00000X
WADI61552513133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered