Provider Demographics
NPI:1407045297
Name:GULLICKSON, CHERYL WALTON (MS,RD,LD,CDE,CNSD)
Entity type:Individual
Prefix:MRS
First Name:CHERYL
Middle Name:WALTON
Last Name:GULLICKSON
Suffix:
Gender:F
Credentials:MS,RD,LD,CDE,CNSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 VETERANS MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76504-7451
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1901 VETERANS MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76504-7451
Practice Address - Country:US
Practice Address - Phone:254-743-2178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-17
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT80471133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered