Provider Demographics
NPI:1760344527
Name:MEDUNICK, NATHANAEL
Entity type:Individual
Prefix:
First Name:NATHANAEL
Middle Name:
Last Name:MEDUNICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 LOUISE LUTHER DR
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:RI
Mailing Address - Zip Code:02864-6013
Mailing Address - Country:US
Mailing Address - Phone:910-712-6206
Mailing Address - Fax:
Practice Address - Street 1:47 LOUISE LUTHER DR
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:RI
Practice Address - Zip Code:02864-6013
Practice Address - Country:US
Practice Address - Phone:910-712-6206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-12-01
Last Update Date:2025-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILDN01311133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty