Provider Demographics
NPI:1871203729
Name:GOPALAN, PUNITHAVATHY (MS,RD,LD,CDCES)
Entity type:Individual
Prefix:
First Name:PUNITHAVATHY
Middle Name:
Last Name:GOPALAN
Suffix:
Gender:F
Credentials:MS,RD,LD,CDCES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 OWLS HEAD DR
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03063-1561
Mailing Address - Country:US
Mailing Address - Phone:603-921-2011
Mailing Address - Fax:
Practice Address - Street 1:10 OWLS HEAD DR
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03063-1561
Practice Address - Country:US
Practice Address - Phone:603-921-2011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-01
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1011335133V00000X
IL32200565133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty