Provider Demographics
NPI:1730960477
Name:FAHMY, GABRIELLA
Entity type:Individual
Prefix:
First Name:GABRIELLA
Middle Name:
Last Name:FAHMY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:845 ANCHOR ST
Mailing Address - Street 2:
Mailing Address - City:MORRO BAY
Mailing Address - State:CA
Mailing Address - Zip Code:93442-2303
Mailing Address - Country:US
Mailing Address - Phone:805-539-9018
Mailing Address - Fax:
Practice Address - Street 1:3889 LONG ST STE 200
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-7581
Practice Address - Country:US
Practice Address - Phone:805-724-6831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-09
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86293018133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered