Healthcare Provider Details

I. General information

NPI: 1912338120
Provider Name (Legal Business Name): KELLY ELAINE GUMPEL RD, CDN, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2013
Last Update Date: 02/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 PAULDING AVE
TARRYTOWN NY
10591-5713
US

IV. Provider business mailing address

60 PAULDING AVE
TARRYTOWN NY
10591-5713
US

V. Phone/Fax

Practice location:
  • Phone: 914-280-0500
  • Fax:
Mailing address:
  • Phone: 914-280-0500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number007906
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: