Provider Demographics
NPI:1427172741
Name:GOURLEY, LISA MARIE (RD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:GOURLEY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 N CENTER AVE
Mailing Address - Street 2:APT 7303
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-4856
Mailing Address - Country:US
Mailing Address - Phone:951-733-4412
Mailing Address - Fax:
Practice Address - Street 1:9961 SIERRA AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-6720
Practice Address - Country:US
Practice Address - Phone:909-427-7263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA916500133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered