Provider Demographics
NPI:1619218906
Name:BERGDOLT, GRETCHEN ANN (RD, CDN, MS)
Entity Type:Individual
Prefix:MS
First Name:GRETCHEN
Middle Name:ANN
Last Name:BERGDOLT
Suffix:
Gender:F
Credentials:RD, CDN, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 TREMONT ST
Mailing Address - Street 2:DEGRAFF MEMORIAL HOSPITAL
Mailing Address - City:NORTH TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120-6150
Mailing Address - Country:US
Mailing Address - Phone:716-690-2093
Mailing Address - Fax:
Practice Address - Street 1:445 TREMONT ST
Practice Address - Street 2:DEGRAFF MEMORIAL HOSPITAL
Practice Address - City:NORTH TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14120-6150
Practice Address - Country:US
Practice Address - Phone:716-690-2093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-12
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006428-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered