Provider Demographics
NPI:1649698820
Name:WARD, GINA R (MS, RD, CD, CDE)
Entity type:Individual
Prefix:MRS
First Name:GINA
Middle Name:R
Last Name:WARD
Suffix:
Gender:F
Credentials:MS, RD, CD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:253 W 1900 S
Mailing Address - Street 2:
Mailing Address - City:CLEARFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84015-4310
Mailing Address - Country:US
Mailing Address - Phone:801-775-9819
Mailing Address - Fax:
Practice Address - Street 1:1600 W ANTELOPE DR
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-1142
Practice Address - Country:US
Practice Address - Phone:801-807-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-03
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5245302-4901133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered