Provider Demographics
NPI:1073596409
Name:LUKE, GAYLE M (RD)
Entity Type:Individual
Prefix:
First Name:GAYLE
Middle Name:M
Last Name:LUKE
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 1:1314 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-4116
Mailing Address - Country:US
Mailing Address - Phone:601-703-4331
Mailing Address - Fax:601-703-3080
Practice Address - Street 1:5009 HWY 493
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39305-1635
Practice Address - Country:US
Practice Address - Phone:601-484-6180
Practice Address - Fax:601-482-0944
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD0265133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q33377Medicare UPIN