Provider Demographics
NPI:1831623446
Name:GAYNOR, MELISSA HOPE (RD, CDE)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:HOPE
Last Name:GAYNOR
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:HOPE
Other - Last Name:LEVINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, CDE
Mailing Address - Street 1:5610 2ND AVE
Mailing Address - Street 2:RM 191
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-3599
Mailing Address - Country:US
Mailing Address - Phone:718-630-8611
Mailing Address - Fax:
Practice Address - Street 1:5610 2ND AVE
Practice Address - Street 2:RM 191
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-3599
Practice Address - Country:US
Practice Address - Phone:718-630-8611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-20
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1108576133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered