Provider Demographics
NPI:1588936660
Name:HORTER, GWEN MICHELLE
Entity type:Individual
Prefix:
First Name:GWEN
Middle Name:MICHELLE
Last Name:HORTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:834 SHOREWOOD DR
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-4905
Mailing Address - Country:US
Mailing Address - Phone:701-520-0855
Mailing Address - Fax:
Practice Address - Street 1:1000 CONEY ST W
Practice Address - Street 2:
Practice Address - City:PERHAM
Practice Address - State:MN
Practice Address - Zip Code:56573-2102
Practice Address - Country:US
Practice Address - Phone:218-347-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-03
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2819133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered