Provider Demographics
NPI:1720824691
Name:WUNDERLICH, MADISON S (RD, LDN)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:S
Last Name:WUNDERLICH
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13114 FOXTAIL FERN DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-2447
Mailing Address - Country:US
Mailing Address - Phone:239-281-4665
Mailing Address - Fax:
Practice Address - Street 1:110 LITHIA PINECREST RD
Practice Address - Street 2:SUITE C PMB 1086
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511
Practice Address - Country:US
Practice Address - Phone:239-281-4665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-01
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND12491133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered