=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275252207
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELE FRADELLA GERARVE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2022
-----------------------------------------------------
Last Update Date | 07/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1515 RIVER RD
-----------------------------------------------------
City | JEFFERSON
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70121-4227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-842-3901
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1514 JEFFERSON HWY
-----------------------------------------------------
City | NEW ORLEANS
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70121-2429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-842-4000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133VN1301X
-----------------------------------------------------
Taxonomy Name | Oncology Nutrition Registered Dietitian
-----------------------------------------------------
License Number | 2557
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------