Provider Demographics
NPI:1578965885
Name:GUNNARE, NICOLE (RD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:GUNNARE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:BRANSFORD-SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4701 MONTGOMERY BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-1219
Mailing Address - Country:US
Mailing Address - Phone:505-727-7819
Mailing Address - Fax:505-727-9237
Practice Address - Street 1:4701 MONTGOMERY BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-1219
Practice Address - Country:US
Practice Address - Phone:505-727-7819
Practice Address - Fax:505-727-9237
Is Sole Proprietor?:No
Enumeration Date:2014-09-17
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLD-0888133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered