Provider Demographics
NPI:1245958800
Name:GANDOLFI, TAEGAN Q (RD)
Entity type:Individual
Prefix:
First Name:TAEGAN
Middle Name:Q
Last Name:GANDOLFI
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-5403
Mailing Address - Country:US
Mailing Address - Phone:585-922-4020
Mailing Address - Fax:
Practice Address - Street 1:625 BROADWAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-5403
Practice Address - Country:US
Practice Address - Phone:315-359-8608
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-19
Last Update Date:2025-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY86328389133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered