Provider Demographics
NPI:1538802608
Name:GENTILE, MIRANDA (RD, LD)
Entity type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:
Last Name:GENTILE
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1353 W 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43212-2923
Mailing Address - Country:US
Mailing Address - Phone:937-657-3889
Mailing Address - Fax:
Practice Address - Street 1:1353 W 3RD AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43212-2923
Practice Address - Country:US
Practice Address - Phone:937-657-3889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-18
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD.08654133V00000X
86069930133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered