Provider Demographics
NPI:1912338120
Name:GUMPEL, KELLY ELAINE (RD, CDN, CDE)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ELAINE
Last Name:GUMPEL
Suffix:
Gender:F
Credentials:RD, CDN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 PAULDING AVE
Mailing Address - Street 2:
Mailing Address - City:TARRYTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10591-5713
Mailing Address - Country:US
Mailing Address - Phone:914-280-0500
Mailing Address - Fax:
Practice Address - Street 1:60 PAULDING AVE
Practice Address - Street 2:
Practice Address - City:TARRYTOWN
Practice Address - State:NY
Practice Address - Zip Code:10591-5713
Practice Address - Country:US
Practice Address - Phone:914-280-0500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-13
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007906133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00695941Medicaid
NY331947Medicare Oscar/Certification
NY00695941Medicaid