Healthcare Provider Details

I. General information

NPI: 1528010600
Provider Name (Legal Business Name): GAIL L UNDERBAKKE RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 05/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 S VINE STREET
BELLEVILLE WI
53508
US

IV. Provider business mailing address

7974 UW HEALTH CT
MIDDLETON WI
53562-5531
US

V. Phone/Fax

Practice location:
  • Phone: 608-424-3384
  • Fax: 608-424-6353
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number220
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: