Provider Demographics
NPI:1790727865
Name:GAUTREAUX, MICHELLE (RDN/LDN)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:
Last Name:GAUTREAUX
Suffix:
Gender:F
Credentials:RDN/LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 MDG
Mailing Address - Street 2:340 MAGNOLIA CIRCLE
Mailing Address - City:TYNDALL AFB
Mailing Address - State:FL
Mailing Address - Zip Code:32403
Mailing Address - Country:US
Mailing Address - Phone:850-283-3826
Mailing Address - Fax:
Practice Address - Street 1:325 MDG
Practice Address - Street 2:340 MAGNOLIA CIRCLE
Practice Address - City:TYNDALL AFB
Practice Address - State:FL
Practice Address - Zip Code:32403
Practice Address - Country:US
Practice Address - Phone:850-283-3826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND3408133V00000X
133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE8812ZMedicare ID - Type Unspecified