Provider Demographics
NPI:1568628196
Name:GUNNISON, MICHELE (RD,CDN)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:GUNNISON
Suffix:
Gender:F
Credentials:RD,CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 VAILS LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:NY
Mailing Address - Zip Code:10509-1725
Mailing Address - Country:US
Mailing Address - Phone:845-669-5049
Mailing Address - Fax:
Practice Address - Street 1:110 VAILS LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:NY
Practice Address - Zip Code:10509-1725
Practice Address - Country:US
Practice Address - Phone:845-669-5049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-04
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006345133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered