Provider Demographics
NPI:1255491676
Name:GILLESPIE, VERNITA RAE (RD, LD, CDE)
Entity Type:Individual
Prefix:MRS
First Name:VERNITA
Middle Name:RAE
Last Name:GILLESPIE
Suffix:
Gender:F
Credentials:RD, LD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 265
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88202-0265
Mailing Address - Country:US
Mailing Address - Phone:505-623-1406
Mailing Address - Fax:505-624-8757
Practice Address - Street 1:405 W COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5209
Practice Address - Country:US
Practice Address - Phone:505-624-8739
Practice Address - Fax:505-624-8757
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM066133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00056342Medicaid