Provider Demographics
NPI:1528010600
Name:UNDERBAKKE, GAIL L (RD)
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:L
Last Name:UNDERBAKKE
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 1:7974 UW HEALTH CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-5531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21 S VINE STREET
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53508
Practice Address - Country:US
Practice Address - Phone:608-424-3384
Practice Address - Fax:608-424-6353
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI220133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered