Provider Demographics
NPI:1689383820
Name:EAGAN, GWENDOLYN MARIE (MS, RD)
Entity Type:Individual
Prefix:MS
First Name:GWENDOLYN
Middle Name:MARIE
Last Name:EAGAN
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 WEST ST
Mailing Address - Street 2:
Mailing Address - City:NORTH BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05257-9405
Mailing Address - Country:US
Mailing Address - Phone:518-593-3318
Mailing Address - Fax:
Practice Address - Street 1:11 WEST ST
Practice Address - Street 2:
Practice Address - City:NORTH BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05257-9405
Practice Address - Country:US
Practice Address - Phone:518-593-3318
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-16
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY86168971133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT10151996Medicaid