Provider Demographics
NPI:1720692007
Name:HUMLIE, GABRIELLE ANASTASIA (LD)
Entity type:Individual
Prefix:MRS
First Name:GABRIELLE
Middle Name:ANASTASIA
Last Name:HUMLIE
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:GABRIELLE
Other - Middle Name:ANASTASIA
Other - Last Name:KENT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2435 NE CUMULUS AVE STE A
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-8805
Mailing Address - Country:US
Mailing Address - Phone:503-472-6161
Mailing Address - Fax:503-434-6290
Practice Address - Street 1:2435 NE CUMULUS AVE STE A
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-8805
Practice Address - Country:US
Practice Address - Phone:503-472-6161
Practice Address - Fax:503-434-6290
Is Sole Proprietor?:No
Enumeration Date:2020-09-03
Last Update Date:2021-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLD-D-10209651133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty