Basic Information
| Provider Information | |||||||||
| NPI: | 1811222722 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUNDERMANN | ||||||||
| FirstName: | LAURA | ||||||||
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| Credential: | RD,CDE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 29 | ||||||||
| Address2: | |||||||||
| City: | GOSHEN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109240029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8456151141 | ||||||||
| FaxNumber: | 8452944366 | ||||||||
| Practice Location | |||||||||
| Address1: | 4 HARRIMAN DR | ||||||||
| Address2: | |||||||||
| City: | GOSHEN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109240000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8456151141 | ||||||||
| FaxNumber: | 8452944366 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2009 | ||||||||
| LastUpdateDate: | 10/09/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133NN1002X | 002712 | NY | Y | Dietary & Nutritional Service Providers | Nutritionist | Nutrition, Education |
No ID Information.