Provider Demographics
NPI:1215238126
Name:GORMANOUS, MARIANTHE DAGAR (MS, LDN, RD)
Entity type:Individual
Prefix:MRS
First Name:MARIANTHE
Middle Name:DAGAR
Last Name:GORMANOUS
Suffix:
Gender:F
Credentials:MS, LDN, RD
Other - Prefix:
Other - First Name:MIMI
Other - Middle Name:
Other - Last Name:GORMANOUS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, LDN, RD
Mailing Address - Street 1:2495 SHREVEPORT HWY # 71
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71360-4044
Mailing Address - Country:US
Mailing Address - Phone:318-473-0010
Mailing Address - Fax:
Practice Address - Street 1:2495 SHREVEPORT HWY # 71
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-4044
Practice Address - Country:US
Practice Address - Phone:318-473-0010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-09
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA858842133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered