Provider Demographics
NPI:1619691912
Name:GELLERSTEDT, EMMA MARIE (RDN)
Entity Type:Individual
Prefix:MISS
First Name:EMMA
Middle Name:MARIE
Last Name:GELLERSTEDT
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 WISCONSIN AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53703-4110
Mailing Address - Country:US
Mailing Address - Phone:309-781-7154
Mailing Address - Fax:
Practice Address - Street 1:621 SCIENCE DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711-1074
Practice Address - Country:US
Practice Address - Phone:608-265-8303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-29
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5028-29133V00000X
171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No171400000XOther Service ProvidersHealth & Wellness Coach
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5028-29OtherSTATE OF WISCONSIN DEPARTMENT OF SAFETY AND PROFESSIONAL SERVICES
IA86253882OtherCOMMISSION ON DIETETIC REGISTRATION