Provider Demographics
NPI:1063987675
Name:WHITELEY, GINA M I (RD, CDE)
Entity type:Individual
Prefix:MRS
First Name:GINA
Middle Name:M
Last Name:WHITELEY
Suffix:I
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8197 KOSSUM WAY
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-4155
Mailing Address - Country:US
Mailing Address - Phone:951-490-2177
Mailing Address - Fax:
Practice Address - Street 1:3100 DOUGLAS BLVD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3866
Practice Address - Country:US
Practice Address - Phone:916-865-1140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-10
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA956089133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered