MEDICARE: NATALIE GUNDERSEN RD, CD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	9109995-4901	UT

General Provider Information

NPI Number	:	1366058406
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NATALIE GUNDERSEN RD, CD

Provider Business Mailing Address
First Line	:	PO BOX 540222
Second Line	:
City	:	NORTH SALT LAKE
State	:	UT
Zip	:	84054-0222
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1036 OLDHAM DR
Second Line	:
City	:	NORTH SALT LAKE
State	:	UT
Zip	:	84054-6009
Country	:	US
Telephone Number	:	847-754-7217
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/22/2020
Last Update Date	:	09/22/2020

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