Provider Demographics
NPI:1114571742
Name:GIMBAR, MICHELLE NICOLE (RDN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:NICOLE
Last Name:GIMBAR
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1747 PIERCE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13903-6641
Mailing Address - Country:US
Mailing Address - Phone:607-434-8894
Mailing Address - Fax:
Practice Address - Street 1:1747 PIERCE CREEK RD
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13903-6641
Practice Address - Country:US
Practice Address - Phone:607-434-8894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-31
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY86057839133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered