Provider Demographics
NPI:1417177718
Name:GUNN, MICHELLE RAE (CERTIFIED DIETITIAN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RAE
Last Name:GUNN
Suffix:
Gender:F
Credentials:CERTIFIED DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N3474 ADAMS ROAD
Mailing Address - Street 2:
Mailing Address - City:BRUCE
Mailing Address - State:WI
Mailing Address - Zip Code:54819
Mailing Address - Country:US
Mailing Address - Phone:715-868-4848
Mailing Address - Fax:715-868-4848
Practice Address - Street 1:N3474 ADAMS RD
Practice Address - Street 2:
Practice Address - City:BRUCE
Practice Address - State:WI
Practice Address - Zip Code:54819
Practice Address - Country:US
Practice Address - Phone:715-868-4848
Practice Address - Fax:715-868-4848
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1280-029133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education