Provider Demographics
NPI:1487278214
Name:GORHAM, RACHEL M R (RD, LD)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:M R
Last Name:GORHAM
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:RACHEL
Other - Middle Name:MEGAN
Other - Last Name:RUBATT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD
Mailing Address - Street 1:4200 DAHLBERG DR STE 300
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4841
Mailing Address - Country:US
Mailing Address - Phone:952-512-5600
Mailing Address - Fax:
Practice Address - Street 1:11225 ULYSSES ST NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-4261
Practice Address - Country:US
Practice Address - Phone:763-302-2600
Practice Address - Fax:763-302-2601
Is Sole Proprietor?:No
Enumeration Date:2020-06-08
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3830133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered