Healthcare Provider Details

I. General information

NPI: 1811222722
Provider Name (Legal Business Name): LAURA GUNDERMANN RD,CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2009
Last Update Date: 10/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 HARRIMAN DR
GOSHEN NY
10924-0000
US

IV. Provider business mailing address

PO BOX 29
GOSHEN NY
10924-0029
US

V. Phone/Fax

Practice location:
  • Phone: 845-615-1141
  • Fax: 845-294-4366
Mailing address:
  • Phone: 845-615-1141
  • Fax: 845-294-4366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number002712
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: