Provider Demographics
NPI:1205532280
Name:GOMEZ RAFFO, MARISELA (RDN)
Entity type:Individual
Prefix:
First Name:MARISELA
Middle Name:
Last Name:GOMEZ RAFFO
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:MARISELA
Other - Middle Name:BELEN
Other - Last Name:GOMEZ BAYOLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:105 SAIL MAKER LN
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:GA
Mailing Address - Zip Code:31324-7402
Mailing Address - Country:US
Mailing Address - Phone:954-980-5455
Mailing Address - Fax:
Practice Address - Street 1:2045 W GRAND AVE STE B
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-1577
Practice Address - Country:US
Practice Address - Phone:888-200-5492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-01
Last Update Date:2025-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY283075133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered