Healthcare Provider Details

I. General information

NPI: 1720371941
Provider Name (Legal Business Name): NICOLE M GUMPF M.S., R.D., L.D.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2011
Last Update Date: 01/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

246 FRIENDSHIP CIR
BEAVER PA
15009-9704
US

IV. Provider business mailing address

246 FRIENDSHIP CIR
BEAVER PA
15009-9704
US

V. Phone/Fax

Practice location:
  • Phone: 724-775-7100
  • Fax:
Mailing address:
  • Phone: 724-775-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDN004492
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: