Provider Demographics
NPI:1699585505
Name:BALTO, GWENDOLINE (RD)
Entity type:Individual
Prefix:
First Name:GWENDOLINE
Middle Name:
Last Name:BALTO
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 1:10525 BIG BEND RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63122-6227
Mailing Address - Country:US
Mailing Address - Phone:312-590-8945
Mailing Address - Fax:
Practice Address - Street 1:10525 BIG BEND RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63122-6227
Practice Address - Country:US
Practice Address - Phone:314-804-1848
Practice Address - Fax:618-209-1962
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-13
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024046426133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered