Healthcare Provider Details

I. General information

NPI: 1447026125
Provider Name (Legal Business Name): GUT GLOW LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2023
Last Update Date: 12/04/2023
Certification Date: 12/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 CONGRESS ST
PORTLAND ME
04101-3505
US

IV. Provider business mailing address

635 W 170TH ST APT 2E
NEW YORK NY
10032-3226
US

V. Phone/Fax

Practice location:
  • Phone: 650-248-4863
  • Fax:
Mailing address:
  • Phone: 650-248-4863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code133VN1501X
TaxonomySports Dietetics Nutrition Registered Dietitian
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: LYNDA FLAVIA LAWRENCE
Title or Position: LEAD DIETITIAN
Credential: RDN, LDN
Phone: 650-248-4863