Provider Demographics
NPI:1083187348
Name:BLAINE, GABRIELLE K (RD, LRD, CDE)
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:K
Last Name:BLAINE
Suffix:
Gender:F
Credentials:RD, LRD, CDE
Other - Prefix:
Other - First Name:GABRIELLE
Other - Middle Name:K
Other - Last Name:HARTZE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2500 FAIRWAY ST
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-2639
Mailing Address - Country:US
Mailing Address - Phone:701-456-4000
Mailing Address - Fax:
Practice Address - Street 1:2500 FAIRWAY ST
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-2639
Practice Address - Country:US
Practice Address - Phone:701-456-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-09
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1184133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered