Provider Demographics
NPI:1376139204
Name:GANDER, ELLEN P (RD, LDN, CEDRD-S)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:P
Last Name:GANDER
Suffix:
Gender:F
Credentials:RD, LDN, CEDRD-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5944 DUNBARTON WAY
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27613-6856
Mailing Address - Country:US
Mailing Address - Phone:513-293-8506
Mailing Address - Fax:
Practice Address - Street 1:1042 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27605-1258
Practice Address - Country:US
Practice Address - Phone:919-781-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-15
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLOO4531133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered