Provider Demographics
NPI:1902430960
Name:DALLE POULOS, GLORIA JEAN (NBC-HWC, FMCHC, CHES)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:JEAN
Last Name:DALLE POULOS
Suffix:
Gender:F
Credentials:NBC-HWC, FMCHC, CHES
Other - Prefix:MS
Other - First Name:GLORIA
Other - Middle Name:
Other - Last Name:DALLE POULOS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NBC-HWC, FMCHC, CHES
Mailing Address - Street 1:6405 FRANCE AVE S STE W440
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2190
Mailing Address - Country:US
Mailing Address - Phone:952-345-4165
Mailing Address - Fax:
Practice Address - Street 1:6401 UNIVERSITY AVE NE
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-4341
Practice Address - Country:US
Practice Address - Phone:507-330-0468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-28
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty