Provider Demographics
NPI:1790162253
Name:MADISON, GINA MARIE (RD)
Entity Type:Individual
Prefix:MRS
First Name:GINA
Middle Name:MARIE
Last Name:MADISON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MISS
Other - First Name:GINA
Other - Middle Name:MARIE
Other - Last Name:DOLENTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:1515 EUBANK BLVD. SE BLDG. 831/832
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87185-1019
Mailing Address - Country:US
Mailing Address - Phone:505-844-4237
Mailing Address - Fax:
Practice Address - Street 1:1515 EUBANK BLVD SE BLDG. 831-832
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87185-1019
Practice Address - Country:US
Practice Address - Phone:505-844-4237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-04
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1067342174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1067342OtherREGISTERED DIETITIAN WITH COMMISSION ON DIETETIC REGISTRATION