Provider Demographics
NPI:1124763180
Name:GOULD, AUDREY (RD)
Entity type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:
Last Name:GOULD
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5370 GRAZING HILL RD
Mailing Address - Street 2:
Mailing Address - City:SHINGLE SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:95682-8051
Mailing Address - Country:US
Mailing Address - Phone:916-769-7544
Mailing Address - Fax:
Practice Address - Street 1:5370 GRAZING HILL RD
Practice Address - Street 2:
Practice Address - City:SHINGLE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:95682-8051
Practice Address - Country:US
Practice Address - Phone:916-769-7544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-03
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA817620133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty