Provider Demographics
NPI:1962725044
Name:GOURGOUMIS, CARA (RD)
Entity type:Individual
Prefix:
First Name:CARA
Middle Name:
Last Name:GOURGOUMIS
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:PSC 482 BOX 1600
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96362-0017
Mailing Address - Country:US
Mailing Address - Phone:315-646-7057
Mailing Address - Fax:
Practice Address - Street 1:PSC 482 BOX 1600
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96362-0017
Practice Address - Country:US
Practice Address - Phone:315-646-7057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-03
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI00992322133V00000X
GALD005704133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered