Healthcare Provider Details

I. General information

NPI: 1417177718
Provider Name (Legal Business Name): MICHELLE RAE GUNN CERTIFIED DIETITIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N3474 ADAMS RD
BRUCE WI
54819
US

IV. Provider business mailing address

N3474 ADAMS ROAD
BRUCE WI
54819
US

V. Phone/Fax

Practice location:
  • Phone: 715-868-4848
  • Fax: 715-868-4848
Mailing address:
  • Phone: 715-868-4848
  • Fax: 715-868-4848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number1280-029
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: