Healthcare Provider Details

I. General information

NPI: 1619691912
Provider Name (Legal Business Name): EMMA MARIE GELLERSTEDT RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2022
Last Update Date: 03/01/2024
Certification Date: 03/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 SCIENCE DR
MADISON WI
53711-1074
US

IV. Provider business mailing address

321 WISCONSIN AVE APT 4
MADISON WI
53703-4110
US

V. Phone/Fax

Practice location:
  • Phone: 608-265-8303
  • Fax:
Mailing address:
  • Phone: 309-781-7154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number5028-29
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: