Healthcare Provider Details

I. General information

NPI: 1376139204
Provider Name (Legal Business Name): ELLEN P GANDER RD, LDN, CEDRD-S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2020
Last Update Date: 12/15/2020
Certification Date: 12/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1042 WASHINGTON ST
RALEIGH NC
27605-1258
US

IV. Provider business mailing address

5944 DUNBARTON WAY
RALEIGH NC
27613-6856
US

V. Phone/Fax

Practice location:
  • Phone: 919-781-4500
  • Fax:
Mailing address:
  • Phone: 513-293-8506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLOO4531
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: